Management Of Medical Emergencies In The Dental Office Fady Faddoul,

Management Of Medical Emergencies In The Dental Office Fady Faddoul, DDS, MSD,FICD Professor and Vice-Chairman Department of Comprehensive Care Director, Advanced Education in General Dentistry Case Western Reserve University School Dental Medicine 05/06/23 1

Management of Medical Emergencies Medical emergencies can and do happen Advances in medicine Longer lifespan Multiple medications Medically compromised Longer appointments 05/06/23 2

Incidence A survey done in the 90’s showed that, over a 10 year period, 90% of dentists have encountered at least one medical emergencies. 05/06/23 3

Types TYPE OF EMERGENCY NUMBER PERCENT Altered Consciousness 17,782 59 Cardiovascular 4,280 14 Allergy 2,887 9.5 Respiratory 2,718 9 Seizures 1,595 5 999 3 Diabetes-Related 05/06/23 4

Management of Medical Emergencies Basic Life Support Advanced Life Support 05/06/23 5

Management of Medical Emergencies Emergency situations Managed properly most emergencies are resolved satisfactorily Mismanaged even benign emergencies can turn disastrous Recognize Position Stabilize Diagnose Treat Refer 05/06/23 6

Management Of Medical Emergencies 1. 2. 3. 4. 5. 6. Recognition Prevention Preparation Basic life support (BLS) Cardiopulmonary resuscitation (CPR) Specific medical emergencies 05/06/23 7

Prevention IS THE BEST TREATMENT Know your patient Never treat a STANGER 05/06/23 8

Prevention 90% of life-threatening situations can be prevented 10% will occur in spite of all preventive efforts (sudden unexpected death) 05/06/23 9

Prevention Medical History Physical Evaluation Vital Signs Dialogue History Determination of Medical Risk Stress Reduction 05/06/23 10

Prevention MEDICAL HISTORY Review Update Medication Medical consultation 05/06/23 11

Prevention PHYSICAL EVALUATION Length of time since last evaluation Vital signs Visual inspection of patients Referral to physician 05/06/23 12

Prevention VITAL SIGNS Blood pressure Pulse rate Respiratory rate 05/06/23 Temperature Height Weight 13

Prevention DIALOGUE HISTORY Putting it all together Check accuracy of medical history Recognize anxiety 05/06/23 14

Prevention DETERMINATION OF MEDICAL RISK. Ability of patient to safely tolerate dental treatment. Does patient represent increased medical risk? Can patient be managed in the dental office? 05/06/23 15

Determination Of Medical Risk American Society of Anesthesiology Physical Status Classification System 05/06/23 16

ASA I A patient without systemic disease A normal healthy patient 05/06/23 Can tolerate stress involved In dental treatment No added risk of serious Complications Treatment modification Usually not necessary 17

ASA II A patient with mild systemic disease Example: -Well-controlled diabetic -Well-controlled asthma -ASA I with anxiety 05/06/23 Represent minimal risk during dental treatment Routine dental treatment With minor modifications -Short early appointments -Antibiotic prophylaxis -Sedation 18

ASA III A patient with severe systemic disease that limits activity but is not incapacitating Example: - a stable angina - 6 mos. Post - MI - 6 mos. Post - CVA - COPD 05/06/23 Elective Dental Treatment is not Contraindicated Treatment Modification is Required - Reduce Stress - Sedation - Short Appointments 19

ASA IV A patient with incapacitating systemic disease that is a constant threat to life Example: - Unstable angina - M I within 6 months - CVA within 6 months - BP greater than 200/115 - Uncontrolled diabetic 05/06/23 Elective dental care should be postponed Emergency dental care only Rx only to control pain and infection Other treatment in hospital (I&D, extraction) 20

ASA V A morbid patient not expected to survive Example: - End stage renal disease - End stage hepatic disease - Terminal cancer - End stage infectious disease 05/06/23 Elective treatment definitely contraindicated Emergency care only to relieve pain 21

Prevention STRESS REDUCTION Premedication Sedation Pain control (intra and post-op) Early appointments Short appointments 05/06/23 22

Preparation Team Effort BLS for all office personnel CPR for all office personnel Emergency drills Emergency phone numbers (911) Emergency equipment 05/06/23 23

BASIC LIFE SUPPORT (BLS) CARDIOPULMONARY RESUCITATION (CPR) 05/06/23 24

SBE Prophylaxis In 2012, the guidelines were updated and now premedication is needed for fewer conditions. The conditions for which premedication is necessary includes: artificial heart valves a history of infective endocarditis a cardiac transplant that develops a heart valve problem the following congenital (present from birth) heart conditions: *unrepaired or incompletely repaired cyanotic congenital heart disease, including those with palliative shunts and conduits *a completely repaired congenital heart defect with prosthetic material or device, whether placed by surgery or by catheter intervention, during the first six months after the procedure *any repaired congenital heart defect with residual defect at the site or adjacent to the site of a prosthetic patch or a prosthetic device 05/06/23 25

SBE Prophylaxis Patients who previously needed antibiotic prophylactic but no longer need them include: mitral valve prolapse rheumatic heart disease bicuspid valve disease calcified aortic stenosis congenital (present from birth) heart conditions such as ventricular septal defect, atrial septal defect and hypertrophic cardiomyopathy 05/06/23 26

SBE Prophylaxis Procedures needing prophylaxis: All dental procedures that involve manipulation of gingival tissue or the periapical region of teeth or perforation of the oral mucosa. procedures that do not require prophylaxis are radiographs, placement of removable prosthesis, and placement orthodontic bracket. 05/06/23 27

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Management of Medical Emergencies Antibiotic Prophylaxis Prophylactic Regimen for Dental Procedures AMOXCICILIN Adults 2 grams Children 50 mg/kg (not to exceed adult dosage) Orally 1 hour before procedure No repeat dose 05/06/23 29

Management of Medical Emergencies Antibiotic Prophylaxis Prophylactic Regimen for Dental Procedures Allergic to Penecillin Adult Children Clindamycin 600 mg 20 mg/kg Cefalexin or Cfadroxil 2 gr. 50 mg/kg Azithromycin or Clanthromycin 500 mg 15mg/kg ORALLY 1 HOUR BEFORE PROCEDURE 05/06/23 30

Management of Medical Emergencies Antibiotic Prophylaxis Prophylactic Regimen for Dental Procedures Unable to take Oral Medication Ampicillin Adults: 2 gr IM or IV Children: 50 mg/kg IM or IV Within 30 minutes of procedure 05/06/23 31

Management of Medical Emergencies Antibiotic Prophylaxis Amoxicillin vs. Penecillin 05/06/23 Both equally effective against Streptococus viridan Amoxicillin is better absorbed from the GI tract, and provides higher and more sustained serum level 2 gr. Provides as effective coverage as 3 gr. With less GI adverse effects. 2nd dosage not required due to prolonged serum level above the inhibitory period for most oral Streptococci. 32

Management of Medical Emergencies Antibiotic Prophylaxis ERYTHROMYCIN No longer recommended due to GI side effects. Practitioners who have used it successfully in the past, may continue to use it following the previously published regimen. 2 gr. 2 hours before procedure 1 gr. 6 hours later 05/06/23 33

Management of Medical Emergencies Antibiotic Prophylaxis Patient already taking antibiotic used for prophylaxis: 1. Select an antibiotic from a different class, rather than increasing the dosage 2. Delay treatment if possible 9 to 14 days after completion of antibiotic to allow usual flora to reestablish Example: Amoxicillin, go to Clindamycin. No Cephalosporin due to cross resistance 05/06/23 34

Management of Medical Emergencies Antibiotic Prophylaxis Prophylaxis for dental patients with TOTAL JOINT REPLACEMENT 05/06/23 35

Management of Medical Emergencies Antibiotic Prophylaxis The most crucial period is up to 2 years following a joint replacement Prophylaxis not recommended for dental patients with: Pins, Plates, and Screws. Prophylaxis is not routinely indicated for most dental patients with total joint replacement 05/06/23 36

Management of Medical Emergencies Antibiotic Prophylaxis Patients at potential increased risk of total joint infection Immunocompromized/Suppressed patients Other Patients: Insulin Dependent diabetics 1st 2 years following joint replacement Previous prosthetic joint infection Malnourishement Hemophilia 05/06/23 37

Management of Medical Emergencies Antibiotic Prophylaxis Procedures and regimens are the same as discussed earlier for SBE prophylaxis. A cephlosporin is preferable to Amoxicillin due to its affinity to cynovial fluids 05/06/23 38