management of emergencies

Question 1

T/F most ARD’s are not life threatening

Answer 1

true - most adverse drug reactions are not life threatening

Question 2

ARD’s are usually due to what three things

Answer 2

1. dentists are at fault
2. some events may be RANDOM
3. some events may be a REASONABLE RISK OF TX - example- if patient faints - neither the dentist or the patient is responsible - sncope is merely unavoidable complication of injections that everyone must accept

Question 3

most common in sedation

Answer 3

overdose
- toxic reaction

clinical manifestations of an overdose are related directly to the NORMAL PHARMOCOLGICAL actions of the agent
- example - sedatives = sleep = more sleep = deeper level of sleep or more duration of sleep

barbs have greatest potential

opioid analgesics are involved with the greater number because opioids are more widely used than barbs

Question 4

ingested vs injected

Answer 4

injected has faster route of transmission

Question 5

which permit tirtration

Answer 5

inhalation and IV routes

altering amount of drug given based on weight

vs. pill = get a pill

Question 6

more erratic absorption seen with

Answer 6

intranasal (IN), intramuscular (IM), and oral

Question 7

if presence of drug sensitivity?

Answer 7

lower than average doses should be administered or diff drug categories substituted

Question 8

cardiac arrest

Answer 8

resp distress most often reason

Question 9

moderate to deep sedation affects

Answer 9

hypothalamis and RAS

Question 10

GA effects

Answer 10

cortex – unconsciousness with progressive respiratory and cardio depression

Question 11

respiratory arrest occurs where

Answer 11

medulla

Question 12

diagnostic clues of overdose reaction

Answer 12

recent administrtion of a ssedative hypnotic drug

lack of response

resp depresision - rapid rate but shallow

ataxia

slurred speech

Question 13

general steps after overdose

Answer 13

step1 - terminate tx

step 2 - position the patient - unconscious = supine and legs slightly elevated

step 3 - airway breathing circulation
ABC ***

look listen and feel for breathe

head tilt and chin lift

step 4 - definitive care
- oxygen, monitor, establish IV line, manage

• definitive management of sedative hypntoic overdose produced by a barbiturate is based on MAINTENANCE of a patent airway and adequacy of ventilation until the patient recovers

step 5 - recovery and discharge

Question 14

flumazenil

Answer 14

benzo antagonist - ,2 mg in 15 seconds waiting 45

Question 15

NO discharge if

Answer 15

patient is alone or if not adequately recovered

needto be standing and walking without assistance

Question 16

therapeutic dosed of meperidine?

what is this

Answer 16

an opioid

analgesia, sedation, euphoris, and a degree of resp depression

Question 17

diagnostic clues of overdose of opioids

Answer 17

altered consciousness

resp depression - slow rate

miosis - contraction / pinpoint pupils

Question 18

not reported allergy

Answer 18

1. nitrous oxide

2. oxygen

Question 19

barbs allergy in who?

manifests as?

Answer 19

more seen with past history of asthma, uticaria, and angioedema

manifests as skin lesions, such as hives, and uticaria

Question 20

meperidine with allergies?

Answer 20

can release histamine locally but this is NOT AN ALLERGIC RXN

along path of vein

Question 21

ANAPHYLACTIC when

Answer 21

type i response

if hypotension is also a clinical component – this term can be applies

can take up to even 60 minutes to cause reaction
- if take longer to develop - more mild response usually

Question 22

four main syndromes with anaphylaxis

Answer 22

1. skin
2. smooth muscle spasms
3. resp distress
4. cardio collapse

typical generalized anaphylaxis - go through a range of these progressively

fatal anaphylaxis– resp and cardio distrubances predominate

Question 23

manage immediate skin rxn?

delayed?

Answer 23

epi 1:10,000
IM 1:1000 or subcutaneous .3mg

histamine blocker - diphenydramine

delayed
IM or IV histamine blocker - diphenhydramine 40 mg

prescription for histamine blocker - oral benedryl 50 mg for 3-5 days

Question 24

bronchospasm is? manage?

Answer 24

resp reaction
wheezing and using accessory muscles to breathe

P-A-B-C

bronchodilator
- ALBUTEROL or epinephrine
IM or subcutaneous 3 ml of 1:1000 dilution for adults or IV .1ml of 1:10000 every 15 to 30

histamine blocker - diphenhydramine - 50 mg intramuscullary or 2mg/kg IM or IV (children

Question 25

caviate to using epi for bronchodilation

Answer 25

does NOT releive bronchospasm produced by leukotrienes

Question 26

laryngeal edema | endpoint must know if not fixed?

Answer 26

when little or no air movement can be heard or felt through the mouth and nose DESPITE exaggereated spontaneous respiratory efforts by patient high pitched crowing and sound of stridor - partially obstructed in presence of respiratory movements LOSES CONSCIOUSNESS DUE TO HYPOXIA, ANOXIA - lack of oxygen to brain?

Question 27

management of laryngeal edema

Answer 27

PABC definitve - give epi maintain airway administer oxygen additional - diphenhydramine 50 mg for adults and 25 for children corticosteroid cricothyrotomy

Question 28

hypotension

Answer 28

systolic bp of 90 mmHg in an ASA I adult (might not require tx) - but same blood pressure in an elderly hypertensive patient may be life threatening

Question 29

causes of hypotension

Answer 29

exceessive premedicattion other drugs like steroids. anti HTN, tranquilizers overdose of sedatives/ anesthetics reflexes vascular absorption of LA hemorrage theres a very long list

Question 30

signs of hypotension

Answer 30

``` chest pain dyspnea systolic below 90 heart failure ischemia ``` WIDE RANGE -- depends on the system it is affecting like could have adverse skin reacions / cold / clammy

Question 31

management of hypotension

Answer 31

directed to its cause PABC if using inhlation anesthetic like NO2 - decrease concentration if opioids or benzo - naloxone or flumazenil if barbs - no antagonist so basic ife support can give fluids -- 5% dextrose and water, physiiologic saline administer vasopressors like dopamine -- reserved for hypotension that is more severe

Question 32

hypertensive - overview

Answer 32

can be normal or common due to level of pain or anxiety control is inadequate -- can try to prevent by readministration of local anesthesia if sustained or significant elevation - must be treated aggressively

Question 33

causes of high blood pressure

Answer 33

light anesthesia or sedation pain hypercabia - more Co2 hypoxia (both these cause catecholamine release) emergence delirium fluid overload - over hydraton hyperthermia pre existing cardiac problems

Question 34

hypertensive crisis level | most common in?

Answer 34

Systolic 250 mm Hg or greater diastolic - is 130 mm Hg or greater most common / likely to occur in patients with chronic, stable hypertension

Question 35

definitive care of hypertensive crisis

Answer 35

adinsiter fluids IV titrate NITROPRUSSIDE -- nipride at an infusion rate of 5 mg/kg/min until the blood pressure is lowered therapeutic range is 5-10 mg/kg/min IV nitro - 50 mg bolus - followed by infusion of 10-20 mg / min - potent vasodilator IV diazoxide - hyperstat - in doses of 1 to 3 mg/kg up to 150 mg

Question 36

cardiac dysrhythmias

Answer 36

detectable with monitoring most common intraoperative complication ranging from 4% to 60% incidence in preoperative dysrhthmias under GA even during extraction of bicuspids - patients receiving local anesthesia and sedation levels can be at 24% (happening but probably under reported))

Question 37

DeRango's observations

Answer 37

1. majority who are monitored with ECG will demonstrate some dys-rhythmia 2. incidence higher in paitents with a past heart history 3. higher in trachea intubated patients 4. more frequent in surgeries lasting more than 3 hours 5. patients receiving digitalis preop (like digoxin) have higher incidence

Question 38

precipitating factors for dysthrhthmias

Answer 38

anestesia like HALOTHANE elevated levels of Co2 pain vagal responses intubation anoxia duration of procedure

Question 39

management of dysrhythmias

Answer 39

ensuring adequate ventilation increasing / decreasing level of anesthesia or sedation and providing adequate pain control continuous ECG monitoring

Question 40

angina and MI

Answer 40

stable angina - thoracic pain, usually substernal - tightness - heavy weight on chest result of mild inadequacy of the coronary circulation - vasodilator drugs and rest can relieve it

Question 41

significance of chest pain for LONGER DURATION

Answer 41

more likely to lead to a presumptive MI than angina

Question 42

status of patients who get an MI

Answer 42

51% are at REST when MI occurs -- where as onset of angina - usually occuring with increased myocardial activity

Question 43

management if NO history of angina

Answer 43

activate EMS | administer O2 and nitro

Question 44

management if history of angina

Answer 44

administer O2 -- if pain resolves -- make modifications in tx next time if pain does not resolve -- activate EMS - administer aspirin and monitor ``` MONA morphine oxygen nitroglyxerine aspirin ```

Question 45

airway obstruction | important to recognize?

Answer 45

if it is chest pain or not (cardiac origin or not)

Question 46

airway obstruction due to

Answer 46

most common cause during sedation or GA is POSTERIOR DISPLACMENT OF THE TONGUE -- into the pharynx as muscle tonus is lost as a result of the CNS depression presence of foreign object in airway - produces partial airway obstruction - rather than total obstruction fluids blood saliva and water / or vomit can produce obstruction

Question 47

signs of NORMAL UNOBSTRUCTED AIRFLOW

Answer 47

LOW WHOOSING SOUND -- through the mouth and nose has a very distinctive low whoosing sound movement of the chest during respiration is minimal and looks "smooth"

Question 48

signs of complete obstruction of airway

Answer 48

absence of sound!!! but observed respiratory movements appear exaggerated with evvident suprclavicular and intercostal soft tissue retraction

Question 49

partial airway obstruction sound

Answer 49

resulting from tongue posteriorly displaced | SNORING SOUND - that is often heard by all persons in the tx room

Question 50

wheezing sound cause? manage?

Answer 50

bronchospams administer a bronchodilator

Question 51

gurgling sound cause? manage?

Answer 51

fluid in airway pharyngeal sunction

Question 52

snoring sound cause? manage?

Answer 52

soft tissue / tongue - displaced in pharynx 1. head tilt 2. anterior displacement of tongue with hemostat or gauze

Question 53

no sound bt exxaggerated resp cause? manage?

Answer 53

complete obstruction 1. head tilt chin lift 2. anterior displacement of tongue 3. pharyngeal suctioning 4. adbominal thrusts 5. cricothyrotomy

Question 54

no sound / no resp cause? manage?

Answer 54

apnea control the ventilation efforts

Question 55

laryngospasm

Answer 55

protective reflex - maintain integrity of airway partial = high pitch sounds complete = no sound with exggerated respiration management - supine position - administer 100 % oxygen and non stop nitrous - positive pressure with oxygen to maintain airway and break the laryngospasm muscle relaxant like succinylcholine 10 mg

Question 56

emesis and aspiratio of foreign material

Answer 56

(vomitting) and possible aspiration of this into airway is one of MOST FRIGHTENING of potential emergencies arising during GA and deep sedation lower pH of material aspirated -- morbidity and death more likely if go into trachea -- potential for disaster

Question 57

three common factors in incidents in dental offices with relatio to morbidity

Answer 57

1. improper preoperative evalutation of the patient 2. lack of knowledge of drug pharm by the dentist 3. lack of adequate monitoring during the procedure

Question 58

monitoring for CNS? Resp? | Cardio?

Answer 58

CNS - direct verbal contact with patient Resp - pulse oximetry - pretracheal stethescope cardio - continuous of vitals - ECG

Question 59

physician desk reference

Answer 59

compilation of prescribing info on rx drugs provides with mandated info for prescriing chemical info function / action indications and contra trial research, side effects, warnings widely available