Fdi Emcvsca PDF

Emergency Medicine
Cardiovascular: SCA and AEDs
2017
2014 Dr. Stanley F. Malamed
2016
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Emergency Medicine
Stanley F. Malamed, DDS
Dentist Anesthesiologist
Emeritus Professor of Dentistry
Ostrow School of Dentistry of USC
Los Angeles, California, USA

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Stanley F. MALAMED, DDS
Emeritus Professor of Anesthesia & Medicine
Ostrow School of Dentistry of USC
I have a relationship with the following company that may be

relevant to this presentation.
I am a consultant to:
Healthfirst Corporation

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malamed@usc.edu malamed@usc.edu
malamed@usc.edu 2017 Dr. Stanley F. Malamed

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The MALAMED Trilogy

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Medical emergencies
CAN and DO
happen
in the practice of
dentistry
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Brazil
2004

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New Zealand
2001
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USA Dental School
2010

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Fiji
2004

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1999 England, Wales, Scotland
Deaths
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4,307 doctors in North America

94.9% have experienced at least one medical
emergency in their office
Average length of career 14.7 years
30,608 emergencies reported
7.1 emergencies per doctor during career
MALAMED SF, JADA 1993 2017 Dr. Stanley F. Malamed

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Syncope 15,407 (50.3%)
Mild allergy 2,583 (8.4%)
Angina pectoris 2,552 (8.3%)
Postural hypotension 2,475 (8.1%)
Seizure 1,595 (5.2%)
ALL patients
Asthmatic attack 1,392 (4.5%) (Adult, Pediatric, Geriatric)
Hyperventilation 1,326 (4.3%) All ages

Epinephrine Rxn 913 (3.0%) N = 4,307
Hypoglycemia 890 (2.9%)
Cardiac arrest 331 (1.1%)
Anaphylaxis 304 (1.0%)
Myocardial infarction 289 (0.9%)
L.A. Overdose 204 (0.7%) 2017
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Legal (moral) Obligation

of the Doctor to the Victim

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Try to
keep the victim alive
until they recover or until
another - more qualified -
individual assumes
responsibility for treatment
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PREPARATION
for
EMERGENCIES
2017
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Preparation of the Office & Staff
1. BasicLife Support training

2. Preparation of Dental Office Staff Members
3. Emergency Assistance
4. Emergency Drugs & Equipment

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1. Basic Life Support
8. Office Emergency TEAM
10. Emergency Drugs & Equipment 2017 Dr. Stanley F. Malamed
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Stanley F. Malamed
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EMERGENCY MANAGEMENT ALGORITHM
P-C-A-B-D
Algorithm for ALL emergency management

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BASIC LIFE SUPPORT

(CPR, Resuscitation, Reanimation)
is THE single-most
important step in the
management of ALL medical
emergencies
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2013 Dr.Reserved
Stanley F. Malamed
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Sternum
Heart
Spinal column
2017
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1. Basic Life Support training


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The Dental Office Emergency Team
2017
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Emergency numbers around the world
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Emergency Medical Services

Europe
112 (most common), 999

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Spain
112, also 061 in some areas

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Spain - Espana

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Africa 2014
EMS in of countries (2014)
<9% Africans have EMS coverage
Most are BLS, government-operated,
fee-for-service

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South Africa
10177
112 from mobile

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Southeast Asia
India 102
Indonesia 118
Malasia 999
Pakistan 15
Philippines 117
Thailand 1554
Vietnam 115

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Australia & Oceania

Australia 000
New Zealand 111

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North America 911,

Mexico 066

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South America:
Argentina 107
Bolivia 118
Brazil 192
Chile 131
Columbia 123
Peru 117
Venezuela 171
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China 120
Japan 119
Maldives 102
South Korea 112, 119

Sri Lanka 110
Taiwan 119
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EMS
Stabilize & Transport 2017 Dr. Stanley F. Malamed

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Critical drugs
THE BASIC SEVEN

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Critical Drugs & Equipment
THE BASIC SEVEN

(as per Malamed)
Five Non-injectable
1. Bronchodilator Two injectable
2. Nitroglycerin
3. Sugar 1. Epinephrine
4. Aspirin 2. Histamine-blocker
5. Oxygen
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Automated External Defibrillator

(AED)

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Chest
Pain
Chest
Pain
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Stanley F.F.Malamed
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Malamed
The HEART is a PUMP
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Right
Right
Left
Left atrium
ventricle
ventricle
- pumps
-- pumps
pumps
venous
arterial
arterial
venousblood
blood
blood
intointo
into
left
right
the
the
ventricle
ventricle
aorta
lungs

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Coronary Arteries
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Malamed
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Syncope 15,407 (50.3%)
Mild allergy 2,583 (8.4%)
Angina pectoris 2,552 (8.3%)
ALL patients
Postural hypotension 2,475 (8.1%) (Adult, Pediatric, Geriatric)
Seizure 1,595 (5.2%)

Asthmatic attack 1,392 (4.5%)
Hyperventilation 1,326 (4.3%) All ages
Epinephrine Rxn 913 (3.0%) N = 4,307
Hypoglycemia 890 (2.9%)
Cardiac arrest 331 (1.1%)
Anaphylaxis 304 (1.0%)
Myocardial infarction 289 (0.9%)
L.A. Overdose 204 (0.7%) 2017
2014Dr.
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Stanley F.F.Malamed
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Malamed
Healthy coronary artery
Progression of coronary artery disease 2017 Dr. Stanley F. Malamed

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Coronary Artery Disease
rtery
Muscular wall of a
Plaque
Lumen
Red Blood Cells
Plaque
Plaque
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Angina Pectoris
Angina pectoris, commonly known as
angina, is the sensation of chest pain,
pressure, or squeezing, often due to
ischemia of the heart muscle from
obstruction or spasm of the
coronary arteries.
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Angina Pectoris
Anything increasing the workload of the heart
can induce an anginal episode
The 4 Es of angina
Exertion
Emotion
Eating
Extremely cold or hot weather
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Transient Myocardial Ischemia = Angina Pectoris
Myocardium not receiving an adequate blood supply becomes

ischemic, leading to the onset of anginal pain
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Angina Pectoris . . . Management
P . . . Conscious = Comfortable (usually upright preferred)
C . . . Assess . . . prn
A . . . Assess . . . prn
B . . . Assess . . . prn
Nitroglycerin
D... Nitroglycerin, O2
D . . . Determine cause, modify future treatment
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Angina Pectoris
With rest or administration of nitroglycerin the myocardial

workload decreases and the chest pain dissipates 2017
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Malamed
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Nitroglycerin
Nitroglycerin produces a 28% increase
in coronary artery lumenal diameter
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Angina pectoris and dentistry
The only time ANGINA should be

considered as a diagnosis in acute chest
pain is where the patient (victim) has a
PREEXISTING HISTORY of ANGINA

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Consider
Myocardial Infarction:
ALWAYS
when there is no prior history
of
cardiovascular disease
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Stanley Malamed
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Consider Myocardial Infarction
In anginal patient when:

Pain worse than usual
3 doses of nitroglycerin fail to relieve discomfort
doses every 5 minutes
Nitroglycerin relieves pain, but pain returns.

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Acute Myocardial Infarction

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Prolonged Myocardial Ischemia
RUPTURE of the PLAQUE into the lumen of the coronary

artery terminates blood flow to an area of myocardium
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Prolonged Myocardial Ischemia =
Myocardial Infarction
Prolonged myocardial ischemia leads to damage and

then death (infarction) of myocardium 2017
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Malamed
Malamed
Malamed
Reserved
Right
Ventricle
Left
Ventricle
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Acute Coronary Syndrome
Narrowed Acute Myocardial Infarction
Obstructed
Angina Pectoris
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First Time Chest Pain

P...
C...
A... 911
B...
D...
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Emergency numbers around the world
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SILENT MI
Women (up to 50%)
Elderly
Diabetics
Do not present with classic signs & symptoms

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Suspected MI . . . Management
P . . . Conscious = Comfortable
(usually upright preferred)
C . . . Assess . . . prn
A . . . Assess . . . prn
B . . . Assess . . . prn
D . . . MONA - Nitroglycerin, O2
D . . . Activate EMS 2017

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Malamed
Malamed
Malamed
MONA
Acronym for the PRE-
HOSPITAL MANAGEMENT OF
A SUSPECTED MYOCARDIAL
INFARCTION
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MONA
Morphine
Oxygen
Nitroglycerin
Aspirin
Prehospital management
68 of suspected MI 2017
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Malamed
MONA = NONA
Morphine = N2O-O2
Oxygen
Nitroglycerin
Aspirin
Prehospital management
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Malamed
Administer O2 or N2O-O2 (50% - 50%)

Administer aspirin
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Nitrous Oxide - Oxygen
50% - 50%
As analgesic as IV morphine
Separates pain from suffering
Sedative Entonox
Relaxes scared patient Dolonox
50% O2
2.5 times ambient air
71
Prehospital management of suspected MI 2017
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Malamed
Aspirin
in Myocardial Infarction
325 mg. POWDERED, if available, with water

20 minute onset
Prevents blood clot (thrombosis) from increasing in size
Increases chances of primary balloon angioplasty being
successful
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Prehospital management of suspected MI 2017
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Malamed
Aspirin
in Myocardial Infarction
Prevents blood clot (thrombosis) from increasing in size
Increases chances of primary balloon angioplasty being
successful
73
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Primary Balloon Angioplasty
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Arrival of EMTs
911
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ECG monitoring
Transport to hospital ED
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When cells are damaged, hypoxic or
anoxic, they become hyperexcitable
Myocardium = DYSRHYTHMIAS 2017 Dr. Stanley F. Malamed

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The Cardiac Conduction System

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Automaticity is the cardiac cell's ability to
spontaneously generate an electrical impulse
(depolarize). Cells that are dedicated to the purpose
of generating an impulse to maintain a heart rate
commensurate with the body's need are called
pacemaker cells.
AUTOMATICITY 2017 Dr. Stanley F. Malamed

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An action potential (yellow)

is initiated in the SA node

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Action potentials are
conducted from the
SA node to the
atrial muscle

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Action potentials
spread through the
atria to the
AV node where
conduction slows

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Action potentials travel
rapidly through the
conduction system to
the apex of the heart

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Action potentials
spread upward
through the
ventricular muscle

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Eventually, the
entire heart
returns to the
resting state,
remaining there
until another action
potential is
generated in the
SA node

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Normal Sinus Rhythm - NSR

QRS
QRS complex
complex
Ventricles
Ventriclesdepolarize
contract T wave
Ventricles repolarize
P wave Atrial repolarization occurs during

Atria contract ventricular contraction 2017
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Premature Ventricular Complexes
Monomorphic (Unifocal)
ALL PVCs look alike
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Monomorphic (Unifocal)
ALL PVCs look alike
Area of ischemic myocardium

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Polymorphic (Multifocal)
PVCs vary in size & shape
MORE CLINICALLY SIGNIFICANT!

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Green arrow = Red arrow =

Normal contraction = PVC =
Blood ejected from left ventricle Little or no blood ejected from left ventricle

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Premature Ventricular Contractions
PVCs
LVEF ranges from 55-70%
Patient is CONSCIOUS
8 of 11 contractions (systoles) are normal,
ejecting blood into the systemic circulation.
Output of blood is 73% of normal

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PVCs
Patient is CONSCIOUS
yet demonstrating S&S of decreased blood flow to
periphery:
Cyanotic mucous membranes
Ashen gray skin color
Diaphoresis
Generalized feeling of fatigue 2017 Dr. Stanley F. Malamed
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Bigeminy
Cardiac output = 50%

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The doctors goal in a

medical emergency situation
Try to keep the victim alive until:

(1) Recovery occurs or
(2) Help arrives to take over
management

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So, what exactly has been done prior
to EMS arrival to PREVENT the
occurrence of cardiac arrest?
Morphine (N2O-O2)
Oxygen
Nitroglycerin
Aspirin 2017 Dr. Stanley F. Malamed
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NOTHING
Ischemic myocardiam still exists;
Victim is symptomatic;
Dysrhythmias still occurring;
But the pump - though damaged - is still
pumping
We have been LUCKY

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Cardiac Arrest
Most OOH-SCA are related to acute
dysrhythmias (VF/ pulseless VT)
Most occur during the 52%

1st hour
after symptom onset
19
8 21
pre-hospital 24 hrs, in-hospital 48 hrs, in-hospital 30 days
52% of MI mortality
Deaths from MI 97
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Cardiac Arrest
Getting into the system
(9.1.1.) 52%
is THE most important thing
that can be done for the
victim of a suspected heart
attack (AMI) Within
1st hour 98
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Ventricular fibrillation is 15
times
more likely to occur in the 1st hour
after the onset of signs and symptoms than in
the next 12 hours.
It develops in the first hour in approximately

36% of persons with acute MI.
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The significant mortality rate

associated with MI is in part
based on the average delay
(4.9 hours)
between the onset of signs
and symptoms and
intervention by the
emergency medical system. 2017 Dr. Stanley F. Malamed
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Cardiac Arrest

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CARDIAC ARREST
occurs when the heart ceases to
PUMP BLOOD
In CARDIAC ARREST
the heart, usually, is still
BEATING
It is no longer PUMPING 2017 Dr. Stanley F. Malamed
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CARDIAC ARREST
occurs when the heart ceases to
PUMP BLOOD
There are 4 rhythms that constitute cardiac arrest
(1) (pulseless) Ventricular Tachycardia
(2) Ventricular Fibrillation (coarse & fine)
(3) Asystole
(4) Pulseless Electrical Activity (PEA)
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Ventricular Tachycardia
VT
VT with a pulse or pulseless VT
The ischemic area of myocardium has taken control.

ALL beats are PVCs 2017 Dr. Stanley F. Malamed
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VT degenerates into a
CHAOTIC, unorganized
quivering of the myocardium -
VENTRICULAR FIBRILLATION
Coarse Ventricular Fibrillation

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Coarse Ventricular Fibrillation
Then, as the myocardium continues to weaken . . . 2017 Dr. Stanley F. Malamed

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Fine Ventricular Fibrillation
Electrical activity lessens 2017 Dr. Stanley F. Malamed

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Cardiac Arrest
Shockable rhythms
Shockable rhythms
Ventricular Fibrillation
coarse & fine
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Cardiac Arrest
Non-shockable rhythms
Pulseless Electrical
Asystole
Activity
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Asystole
Silent Heart
Flat Line

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NOT A
SHOCKABLE RHYTHM
Asystolic Cardiac Arrest

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What happens when the heart

stops PUMPING blood?

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Blood pressure falls to zero, (<60mmHg)
Pulse is not palpable,
Consciousness is lost, and
Respirations cease.
And the victim is . . .
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DEAD
UNCONSCIOUS
NO PULSE
NOT
BREATHING
clinically, DEAD 2017 Dr. Stanley F. Malamed

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Sudden Cardiac Arrest
In the absence of any treatment

death is a certainty 2017 Dr. Stanley F. Malamed
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Sudden Cardiac Arrest
Doing something gives the victim

a chance at survival 2017 Dr. Stanley F. Malamed
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Cardiac Arrest
UNCONSCIOUS
NO PULSE
NOT
BREATHING
Clinical Death 2017 Dr. Stanley F. Malamed

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Our goal in resuscitation is to

prevent the PERMANENT death of
the victim.
Cells in the victims body will die when they use up
all of the O2 available to them
CELLULAR or BIOLOGICAL death occurs
Biological death is irreversible

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The time between the
occurrence of
CLINICAL and BIOLOGICAL
DEATH represents the period
in which RESUSCITATION
may be successful
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Pre-Sudden Cardiac Arrest

Time = up to 1 hour before SCA
Signs & symptoms

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Time 0
Onset of Sudden Cardiac Arrest

VT or VF

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Within 10-Seconds
Loss of consciousness

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4 - 6 Minutes
Brain damage begins

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10 - 14 Minutes
Biological (cellular) death

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Surviving Sudden Cardiac Arrest
Brain cells (neurons) have a high
metabolic rate.
A degree of permanent neurologic deficit can

be expected when neurons are deprived of
O2 for 4-6 minutes. 2017 Dr. Stanley F. Malamed
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Therapeutic Hypothermia
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Therapeutic Hypothermia

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No BLS
Delayed EMS, Delayed BLS Defibrillation:
&
Death . . . or . . .
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No BLS
Delayed EMS, Delayed BLS Defibrillation: &
7 Minutes of Cerebral Anoxia
Global Neurological Damage
Begin brain damage
Severe brain damage 2017 Dr. Stanley F. Malamed

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A very important fact about CPR (Basic Life Support):
Basic life support . . .

Circulates oxygenated blood . . .
Does NOT convert cardiac arrest into a

functional rhythm (e.g. NSR)
BLS simply increases the time during which the

myocardium is still alive

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NO CPR
CPR
Early BLS duration of VF (fine VF)

+ delayed defibrillation 2017 Dr. Stanley F. Malamed
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ANY rhythm
is better than
NO rhythm
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Early BLS + early defibrillation (coarse VF)
~20% survival

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Early BLS + very early defibrillation (coarse VF)
Up to 74% in some situations (Las Vegas)

Neurological deficit unlikely
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What is responsible for the
difference in survival rates
from OOH SCA?

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EMS arrival
Survival Rates
No CPR Defibrillation
Delayed
0 - 2% survive
Defibrillation
CPR Defibrillation
Early CPR
Delayed 2 - 8% survive
Defibrillation
CPR Defibrillation
Early CPR
20% survive
Early
Defibrillation
CPR Defibrillation ACLS

Early CPR
Very early defib. up to 74% survive
Early ACLS
minutes 2 4 6 8 10
TheBYSTANDER-INITIATED BLS
TIME from COLLAPSE to DEFIBRILLATION 2017 Dr. Stanley F. Malamed
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How critical is response time to survival?
In the absence of CPR, for every minute a victim

is in cardiac arrest the chance of survival
decreases by between 7% and 10%.
Survival to
hospital discharge

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Survival to
hospital discharge
2010 AHA Guidelines for CPR and ECC. Circulation 122:S706, 2010All Rights Reserved
DTW
ORD
NYC
LAX 7% Survival to Hospital Discharge
BHM
SLC Eisenberg M. JAMA 300:1423-1431, 2008
DFW
ROC
MEM 12%
TUC
SFO
FAT 15%
IAH
MSP
PIT
PDX
23%
Iowa
MIA
MKE 50%
RST 62%
SEA
0 18 35 53 70
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Survival Rates from SCA

Survival - to hospital discharge -
is dependent upon:
Bystander initiated CPR
Time from collapse to defibrillation

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How critical is response time to survival?
With CPR initiated prior to EMS arrival, for every

minute a victim is in cardiac arrest the chance of
survival decreases by between 3% to 4%.
Survival to
hospital discharge

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Survival to
hospital discharge
2010 AHA Guidelines for CPR and ECC. Circulation 122:S706, 2010 All Rights Reserved
Bystander Initiated CPR
No
Yes

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30-day
survival
30-day
survival

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Time Saved Saved
(min) YES NO
3 380 104
4 355 89
30-day 6 291 58
survival
8 228 40
30-day
10 157 27 survival
12 98 18
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Automated External Defibrillators

(AEDs)

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How to use an AED
Simplistically, an AED is a battery

operated computer which is
capable of determining whether or
not VF/VT is present.
VF/VT present:
SHOCK ADVISED

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How to use an AED
Any rhythm other than VF/VT

PEA, asystole, NSR
NO SHOCK ADVISED
Check airway
Check breathing
Check pulse
If no pulse, continue CPR

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How to use an AED
VF . . . chaotic, uncordinated quivering of myocardium
Coarse VF

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AED delivers a biphasic (2 shocks)

shock across the chest - through the
How an AED works myocardium - depolarizing all
myocardial cells at the same time.

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How an AED works
AED delivers a biphasic (2 shocks) shock across the chest -
through the myocardium - depolarizing all myocardial cells at the
same time, producing . . .
ASYSTOLE
Defibrillation
Coarse VF Asystole
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Dr. Stanley F. Malamed
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How an AED works
Asystole
NSR 2012 Dr. Stanley F. Malamed

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2013 Dr. Stan

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How an AED works
AUTOMATICITY
Heart muscle
- MYOCARDIUM -
loves to contract
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The more alive the

myocardium when depolarized
the more likely it is that the SA
node will spontaneously
depolarize inducing a
normal sinus rhythm.
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Can the chest be compressed adequately
with the victim in the dental chair?
YES
Lepere AJ, Finn J, Jacobs I
Efficacy of cardiopulmonary resuscitation performed in a dental chair
J Australian Dental Association 48(4) 244-247, 2003 (December)
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Time to delivery of an automated external defibrillator

using a drone for simulated out-of-hospital cardiac
arrests vs Emergency Medical Services
Median time from call to dispatch (drone launch)- DRONE = 3 seconds
Median time from call to dispatch - AMBULANCE = 3 minutes
Median time from dispatch to arrival - DRONE = 5.21 minutes
Median time from dispatch to arrival - AMBULANCE = 22 minutes
Claesson A, Backman A, Ringh M, Svensson L etal
J Amer Med Assoc 317(22): 2332-2333, 2017

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J Amer Med Assoc 317(22): 2332-2333, 2017 2017 Dr. Stanley F. Malamed
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Stockholm, SWEDEN, October 2016
J Amer Med Assoc 317(22): 2332-2333, 2017

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Time to delivery of an automated external defibrillator
using a drone for simulated out-of-hospital cardiac
arrests vs Emergency Medical Services
J Amer Med Assoc 317(22): 2332-2333, 2017 2017 Dr. Stanley F. Malamed
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So . . .
In Conclusion
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Rules to Remember
The very first step in management of all

medical emergencies is
BASIC LIFE SUPPORT,

as needed
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Emergency Management
non-Cardiac arrest Cardiac arrest
P . . . position P . . . position
C . . . circulation Drug therapy is C . . . circulation
ALWAYS
A . . . airway secondary to
basic life support
A . . . airway
B . . . breathing B . . . breathing
D . . . definitive care D . . . defibrillation
2017
2014Dr.
2016 Dr.Stanley
Stanley F.F.Malamed
Malamed
All
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P-C-A-B-D
Try to keep the victim alive

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www.healthfirst.com
www.elsevier.com 2017 Dr. Stanley F. Malamed
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Emergency Medicine
2017
2014Dr.
2017
2016 Dr.Stanley
Stanley F.F.Malamed
Malamed
All
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Rights Reserved
Reserved
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malamed@usc.edu
THANK YOU THANK YOU

for LISTENING! for LISTENING!
All Rights Reserved

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Emergency Medicine

Cardiovascular: SCA and AEDs

2017 Dr. Stanley F. Malamed

I have a relationship with the following company that may be

2017 Dr. Stanley F. Malamed

malamed@usc.edu 2017 Dr. Stanley F. Malamed

2017 Dr. Stanley F. Malamed

2017 Dr. Stanley F. Malamed

2017 Dr. Stanley F. Malamed

2017 Dr. Stanley F. Malamed

4,307 doctors in North America

MALAMED SF, JADA 1993 2017 Dr. Stanley F. Malamed

Hyperventilation 1,326 (4.3%) All ages

Legal (moral) Obligation

2017 Dr. Stanley F. Malamed

1. BasicLife Support training

2017 Dr. Stanley F. Malamed

Preparation of the Office & Staff

2017 Dr. Stanley F. Malamed

BASIC LIFE SUPPORT

1. Basic Life Support training

2017 Dr. Stanley F. Malamed

1. Basic Life Support training

2017 Dr. Stanley F. Malamed

Emergency Medical Services

2017 Dr. Stanley F. Malamed

2017 Dr. Stanley F. Malamed

2017 Dr. Stanley F. Malamed

2017 Dr. Stanley F. Malamed

Emergency Medical Services

2017 Dr. Stanley F. Malamed

2017 Dr. Stanley F. Malamed

Emergency Medical Services

Australia & Oceania

New Zealand 111

2017 Dr. Stanley F. Malamed

North America 911,

2017 Dr. Stanley F. Malamed

Emergency Medical Services

South Korea 112, 119

Stabilize & Transport 2017 Dr. Stanley F. Malamed

1. Basic Life Support training

2017 Dr. Stanley F. Malamed

2017 Dr. Stanley F. Malamed

THE BASIC SEVEN

Automated External Defibrillator

2017 Dr. Stanley F. Malamed

The HEART is a PUMP

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Seizure 1,595 (5.2%)

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With rest or administration of nitroglycerin the myocardial

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The only time ANGINA should be

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Consider Myocardial Infarction

In anginal patient when:

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Prolonged Myocardial Ischemia