TRIAGE & EMERGENCY SERVICES

Question 1

• Triage is the process of

Answer 1

sorting injured people based on their need for immediate
medical treatment as compared to their chance of benefiting from such care.

Question 2

• Triage is done in (3)

Answer 2

emergency rooms, disasters, and wars, when limited medical
resources must be allocated to maximize the number of survivors.

Question 3

White tags -

Answer 3

(dismiss) are given to
those with minor injuries for whom a
doctor’s care is not required

Question 4

Green tags -

Answer 4

(wait) are reserved for
the “walking wounded” who will
need medical care at some point,
after more critical injuries have
been treated

Question 5

Yellow tags -

Answer 5

(observation) for
those who require observation (and
possible later re-triage). Their condition is
stable for the moment and, they are not in
immediate danger of death. These victims
will still need hospital care and would be
treated immediately under normal
circumstances

Question 6

Red tags -

Answer 6

(immediate) are used to label
those who cannot survive without
immediate treatment but who have a
chance of survival.

Question 7

Black tags -

Answer 7

(Expectant) are used for the
deceased and for those whose injuries are so
extensive that they will not be able to survive
given the care that is available

Question 8

Dentists in the military or disaster control are often used to — thus freeing the medics to work critical care.
ANY 1st RESPONDER NEEDS AND MUST USE THIS TRAINING.
Additionally, dentists are used to

Answer 8

triage
identify burned or other unidentifiable bodies for identification/legal purposes

Question 9

YOU CAN’T CONTROL THE NEEDS/DESIRES OF PATIENTS
BUT: You DO need to perform a

Answer 9

“type of TRIAGE” to determine
their condition and Tx needs. (don’t just staple a black tag to
their forehead & walk off)

Question 10

It would be ideal to have every patient in your practice pursuing a
* However REAL LIFE gets in the way:
* Sometimes people are simply in the NEED of HELP

Answer 10

strict &
planned comprehensive dental program. (GOAL)

Question 11

What IF they are
actually having a Heart
attack, Diabetic crisis,
Asthma attack etc. and
only THINK they have a
toothache ???
#1 priority:

Answer 11

SYSTEMIC PROBLEMS

Question 12

How you handle it is up to you:
* If you are in PAIN; you want ACTION RIGHT NOW
* You want HELP with an unplanned complication
* You may be in a situation where you know you have neglected health
* You may be in a situation where you don’t have the $ to proceed
* You may be in a situation where you can’t take the time off work

Life may have dealt you a whole bunch of problems which comprise multiple glowing embers any of which can erupt into a raging emergency at any time. (You may have NO EMERGENCY FUND)
This may be one of those times and the last thing patient wants is advice or counseling:

Answer 12

Don’t Preach: Don’t Educate. . . “JUST STAMP OUT THE CURRENT FIRE”
You COULD refer them to someone less busy; you don’t have to do it all. Just provide a path (Call D. Society)

Question 13

HOW CAN YOU HELP THIS PERSON?
* You MUST START with a —
* You MUST START with a thorough & appropriate —
* You MUST PERFORM appropriate —
* You MUST develop an accurate —
* You MUST envision an appropriate —
It doesn’t take an hour and
a half to get this done

Answer 13

HEALTH HISTORY.
EXAMINATION/STUDIES
CLINICAL TESTING/RADIOGRAPHS
DIAGNOSIS
TREATMENT PLAN (with OPTIONS)

Question 14

DECIDE WHAT OPTIONS EXIST:
* Present ALL OPTIONS in clearly understandable —
* Present the — in simple terms
* Don’t FORGET to appraise the PATIENT of THEIR —

Answer 14

LANGUAGE
RISKS & BENEFITS
Responsibilities

Question 15

Don’t FORGET to appraise the PATIENT of THEIR Responsibilities
* — required for each option
* — required for each option (availability of TX and # of visits, etc.)
* — required for each option
* Expected (2) for each option

Answer 15

Costs
Time
Maintenance
Prognosis and Longevity

Question 16

ONLY NOW CAN YOU ASK THE PATIENT TO BECOME INVOLVED in his/her
treatment as regards their desires and expectations. The — drives the
bus, and they must be fully informed and then they must make their
decision regarding which option they wish for their TREATMENT
(if mentally capable)

Answer 16

patient

Question 17

BEWARE of some COMPLICATIONS:
* The patient MUST —
* The patient MUST HAVE reasonable —:
* The treatments must be professionally —

Answer 17

UNDERSTAND (or no permission for Tx exists)
expectations
reasonable

Question 18

The Professional must be responsible to avoid
— options in presenting to the patient.

Answer 18

untoward/unreasonable

Question 19

The Professional must be responsible to avoid
untoward or unreasonable options in presenting to the patient
(5)

Answer 19

• IS THE TOOTH STRATEGIC AND FUNCTIONAL?
• IS THE TOOTH REASONABLY RESTORABLE?
• IS THERE A PERIODONTAL SITUATION WHICH IS COMPROMISING?
• ARE THERE OTHER QUESTIONABLE INVOLVEMENTS?
• IS THE TREATMENT REASONABLY AVAILABLE?

Question 20

It doesnt take an hour and a half to get this done:

Answer 20

time is our most precious resource

Question 21

IS THE TREATMENT REASONABLY AVAILABLE?
Has to be done in Advanced Endo $ + Wait?
Must have crown-lengthening + post and build-up Buildup and crown
Patient leaving the country in 3 days
Patient has to travel 200 miles to get here
Patient can’t get off work or has no $

Answer 21

adv endo
build up and crown
travel
cost, time

Question 22

WHEN THE PATIENT REASONABLY
DECIDES:
* AND THE EMERGENCY TX IS COMPLETED & PATIENT COMFORTABLE.
* THEN YOU CAN LECTURE TO THEM ABOUT

Answer 22

THE BENEFITS OF COMPREHENSIVE DENTAL CARE & MAYBE THEY WILL CHOOSE TO BECOME YOUR REGULAR PATIENT & MAYBE THEY WILL CHOOSE TO
WAIT FOR THE NEXT EMERGENCY TO OCCUR. OR NOT. YOU CANNOT FORCE THEM.

Question 23

WE DO HAVE MORAL, ETHICAL AND PROFESSIONAL OBLIGATIONS:
* We may NOT begin treatment and then fail to complete same & we may NOT propose to offer to provide any treatment for which we are not qualified. Nor may we refer the patient to anyone whom —
* We may NOT refuse to provide treatment to the patient for any reason covered by a —
* We MAY refuse treatment to any patient for any reason not covered as a —
as long as we —

Answer 23

we do not know to be qualified.
federally “protected group”.
federally “protected group”
have not begun any treatment.

Question 24

NOW that we have defined the playing
Field:
* How CAN we help the patient effectively & efficiently in an emergency?
(3)

Answer 24

1. Patient having Symptomatic Irreversible Pulpitis but no PA sensitivity, no
   no PARL and no swelling no fever.
2. PULP EXPOSURES
3. Patient having Symptomatic Irreversible Pulpitis (or AIP or Necrotic
   Pulp) WITH PA sensitivity, PARL and swelling or fever.

Question 25

Want to make a new: (3)

Answer 25

Friend Patient Disciple

Question 26

Help a person escape from PAIN: (3)

Answer 26

Help a person escape from PAIN: * Best practice builder ever! * Instant trust * Even YOU will feel better for helping

Question 27

ANY Tooth with Irreversible Pulpitis or PA Pathology of Endodontic Origin is Best Treated by --- constraints (3)

Answer 27

TOTAL Pulpectomy and RCT. * TIME CONSTRAINTS: * $ CONSTRAINTS: * Other CONSTRAINTS:

Question 28

* “EMERGENCY” TX: MEANS - Do the best we can to stop the pain at the time -until we have time to do the complete RCT. (If we accept the case). If we BEGIN any Tx, If we DON’T COMPLETE it; If we DON’T begin any Tx;

Answer 28

we are bound to complete the Tx. we can be charged with “Abandonment” we can REFER & avoid the Liability

Question 29

1. Patient with Symptomatic Irreversible Pulpitis but no PA involvement, no PARL & no swelling nor fever. (NOT sens. to PERCUSSION) Tx:

Answer 29

emergency Vital Coronal Pulpotomy

Question 30

1. Patient with Symptomatic Irreversible Pulpitis but no PA involvement, no PARL & no swelling nor fever. (NOT sens. to PERCUSSION Expected Outcome: (4)

Answer 30

- Absence of presenting pulpal pain - Should remain comfortable for a short period of time until canals become necrotic - Make appointment in Endo. (Undergrad or Advanced) prn - Will require RCT & Crown at a later date. EMERGENCY TREATMENT

Question 31

2a. Asymptomatic Vital Pulp Exposure (without Pain): (3) Next:

Answer 31

Deep Caries Vital Pulp exposure Clean & Covered Cover with cotton pellet and restore using Paracore + 2 Radiographs

Question 32

2a. Asymptomatic Vital Pulp Exposure (without Pain): HOW TO: (7)

Answer 32

- DO ALL CLINICAL TESTING & RECORD (TEST AT LEAST 3 TEETH AS “BASELINE”) - FILL OUT ENDO. DIAGNOSIS FORM (BEFORE O&R IF PULP EXPOSURE MAY OCCUR) - ISOLATE TOOTH IN QUESTION WITH DENTAL DAM - REMOVE ALL CARIES & UNSUPPORTED ENAMEL (If pulp is exposed) - DISINFECT WITH 8.3 % NaOCl and ARREST HEMORRHAGE, PULPCAP EXPOSURE WITH DYCAL & COTTON & PLACE TEMPORARY RESTORATION SUCH AS PARACORE - AFTER RESTORATION, TAKE 2 RADIOGRAPHS ( 1 STRAIGHT-ON AND 1 AT 20 DEGREE SHIFT SHOT) - CONTACT ANY ENDO FACULTY ON EXCHANGE E-MAIL (SUBJECT OF E-MAIL IS “PULP EXPOSURE”) INCLUDE PATIENT NAME & CHART #, TOOTH INVOLVED AND BRIEF HISTORY.

Question 33

2b. Asymptomatic NON-Vital Pulp Exposure (without Pain): HOW TO: (SAME AS VITAL) (7)

Answer 33

- DO ALL CLINICAL TESTING & RECORD (TEST AT LEAST 3 TEETH AS “BASELINE”) - FILL OUT ENDO. DIAGNOSIS FORM (BEFORE O&R IF PULP EXPOSURE MAY OCCUR) - ISOLATE TOOTH IN QUESTION WITH DENTAL DAM - REMOVE ALL CARIES & UNSUPPORTED ENAMEL (If pulp is exposed) - DISINFECT WITH 8.3 % NaOCl and ARREST HEMORRHAGE, PULPCAP EXPOSURE WITH DYCAL & COTTON & PLACE TEMPORARY RESTORATION SUCH AS PARACORE - AFTER RESTORATION, TAKE 2 RADIOGRAPHS ( 1 STRAIGHT-ON AND 1 AT 20 DEGREE SHIFT SHOT) - CONTACT ANY ENDO FACULTY ON EXCHANGE E-MAIL (SUBJECT OF E-MAIL IS “PULP EXPOSURE”) INCLUDE PATIENT NAME & CHART #, TOOTH INVOLVED AND BRIEF HISTORY.

Question 34

Symptomatic Vital or Non-VITAL Pulp Exposure (with Pain):

Answer 34

Place Cotton and Cavit and refer to E-Chair or Endo as indicated by symptoms

Question 35

Symptomatic Vital or Non-VITAL Pulp Exposure (with Pain): HOW TO: (5)

Answer 35

- Remove all caries & unsupported enamel - Disinfect & arrest any hemorrhage with NaOCl - CALL FOR Endo. Consult (No treatment will be provided by Endodontist doing consult) - Possible Pulpotomy or Pulpectomy in E-Chair (RESTORATION AS REQUIRED) - Make appointment in Endo. (Undergrad or Advanced) as indicated BY CONSULT Deep Caries Vital Pulp exposure Clean& Covered Vitrebond

Question 36

3. Symptomatic Apical Periodontitis (with or without Symptomatic Irreversible Pulpitis): If you identify apical periodontitis of endodontic origin especially in multi-canaled teeth, you may have any combination of --- However, you can be CERTAIN WHEN WE HAVE PERIAPICAL INFLAMATION of PULPAL ORIGIN that Emergency Tx will only be effective with ---

Answer 36

pulpal activity from “normal” through inflamed & infected to necrotic (may have PARL or not yet visible). complete pulpal extirpation (pulpectomy) and that RCT is indicated for this tooth in the near future.

Question 37

3. Symptomatic Apical Periodontitis (with or without Symptomatic Irreversible Pulpitis): Expected Outcome: (4)

Answer 37

-Immediate cessation of pulpal pain. -Tooth will remain sensitive to percussion and biting for up to 3 days - Make appointment in Endo. (Undergrad or Advanced) prn - Will require RCT & Crown

Question 38

EMERGENCY PULPECTOMY TECHNIQUE:

Answer 38

- Gain Adequate Analgesia & Isolate tooth - Access and locate canals - Use apex locator and #10 file to find patency - Enlarge 1mm. Short of patency with a #15 file - Enlarge 2mm. Short of patency with a #20 file - Enlarge 3mm. Short of patency with a #25 file - Irrigate copiously between each instrument with 8.3% NaOCl - Dry with paper points and place CaOH in all canals, cotton and IRM. - Help patient obtain appointment in Pre-doc endo or Advanced endo as indicated

Question 39

This tooth is SENSITIVE To BITE and SWALLOW: We swallow 3000 x daily = 3000 pains Would this be a good time to REDUCE the ---? Would you want to do this B4 you put the --- ON? Would you want to wait and do it LATER when you foul up your ---?

Answer 39

OCCLUSION DAM Working Length

Question 40

EMERGENCY PULPECTOMY TECHNIQUE: BENEFITS: (4)

Answer 40

- removal of irritants, toxins and substrate - path to patency obtained & retained - allows NaOCl to WORK - provides space for CaOH

Question 41

How MUCH of this are YOU willing & able to do? * --- to the rescue! * Do YOU want to ASSUME the ---? * Do YOU want to ASSUME the ---?

Answer 41

CASE SELECTION RESPONSIBILITY LIABILITY

Question 42

Do YOU want to ASSUME the LIABILITY? * Do you have the ---? * Do you have the ---? * Do you have ---? * WHAT IS BEST FOR THE ---? * What is BEST for Your Practice? * Can you make $ doing it? DEVELOP YOUR --- PARACHUTE

Answer 42

Training & Skills Facilities & Instruments/Supplies TIME PATIENT REFERRAL

Question 43

Your radiograph may look like this and your patient (although obviously in pain) shows no extraoral swelling localized swelling only and no lymphadenopathy or fever; you may elect to do I & D in the office and/or open the tooth for pulpectomy. If you open into the pulp, you may be greeted by a fountain of pus followed by blood and finally serous fluid. Following pulpectomy and shaping, You should then --- Patient’s pain will be greatly reduced by these easy treatments and RCT can later proceed as usual. If the swelling is fluctuant; it may be prudent to incise the most dependent portion of the swelling. THIS WILL OFTEN --- Place the patient on --- mg. of ibuprofen q 4-6 h. for 1-3 days. Be sure to call the patient that evening after to see how well they are doing. Tx them the next day if fluid from the tooth was copious & difficult to dry.

Answer 43

dry the canals and close with CaOH, cotton and temp. filling. GAIN IMMEDIATE RELIEF FROM THE SEVERE PAIN 600

Question 44

You might have the exact same radiographic image but the patient comes in looking like this with extreme extra-oral swelling, obvious cellulitis, and spiking fever and exquisite pain Remember: NEVER try to diagnose from the --- alone. You MUST EXAMINE the patient! You are NOT TRAINED to treat this extremely acute problem which is life-threatening. Call your oral surgeon friend or ER and get this patient admitted to the Hospital at once. This is AT LEAST a --- & VERY SERIOUS! In HOSPITAL: This patient was having difficulty in deglutition and also in breathing. As you can see, an emergency tracheotomy was done STAT to save his life and restore respiration. It turns out to be

Answer 44

radiograph Submandibular Cellultis “Ludwig’s Angina” and shows the 3 drains necessary to treat the 3 fascial spaces involved.

Question 45

“Ludwig’s Angina” and shows the 3 drains necessary to treat the 3 fascial spaces involved. . Concern at this point is keeping the patient alive; Move Quickly & Correctly YOUR CHALLENGE IS TO KNOW THE DIFFERENCE AND BE ABLE TO DO A TYPE OF DENTAL TRIAGE AND MOVE RAPIDLY TO INSURE THE HEALTH OF THE PATIENT. Involves:

Answer 45

Submandibular space Sublingual space Submental space

Question 46

Ludwig’s Angina: Life Threatening Be especially vigilant with infections of mandibular molars (especially 2nd & 3rd Molars) WHY:

Answer 46

2nd & 3rd Molars often are located with their root apices located inferior to the mylohyoid M. therefore, allowing ready access for infection to enter the submandibular space encouraging cellulitis to occur in that space and also in associated fascial spaces.

Question 47

What about CAA? (RARELY AN EMERGENCY) Identified by DST: WHY? In the illustration shown, you may only need to assure that the DST is open and actively draining and prescribe warm ---. Then you may proceed with RCT/Crown if total situation justifies the procedure. In certain cases, the ostium of the DST may become closed causing localized swelling and discomfort and a simple --- may be required as emergency Tx before proceeding to RCT.

Answer 47

Patient is generally comfortable and pain medication and antibiotics are NOT indicated for the healthy patient. intraoral rinses I&D

Question 48

What about CAA? CAA may appear on the surface of the face TREATMENT

Answer 48

IS THE SAME; TREAT THE CAUSE (RCT) You don’t need a plastic surgeon

Question 49

What about Deep Caries - Rev.or Irrev. Pulpitis? You MUST do your Sensibility Testing to determine if you are dealing with (3) ACCURATE DIAGNOSIS suggests CORRECT TREATMENT Rev. Pulpitis: IRREV. PULPITIS: Necrotic Pulp: PULP Capping is ONLY an --- for (2)

Answer 49

reversible pulpitis, irreversible pulpitis or necrosis Symptomatic Treatment RCT or T.E. RCT or T.E. INTERIM TREATMENT IRREV. PULPITIS or NECROTIC PULP