Medical Emergency Handbook

Kenneth E. Fleisher, DDS, FACS, Clinical Associate Professor

Robert S. Glickman, DMD, Professor and Chair

Department of Oral and Maxillofacial Surgery

New York University College of Dentistry
 Outline
q Basic emergency equipment
q Required drugs
q Oxygen delivery systems
q Medical emergency
• NYUCD Medical emergency protocol
• Chest pain
─ Angina
─ MI
• Loss of consciousness
─ Hypoglycemia
─ Vasovagal
─ Postural/Orthostatic hypotension
• Seizure
• Shortness of breath
─ Hyperventilation
─ Foreign body aspiration
─ Asthma
• Allergic reaction
 Basic Emergency Equipment

q Eyes (doctor, assistant)

q Portable oxygen (E size)
q Oxygen delivery systems
• Nasal cannula
• Face mask
• Nonrebreathing mask with oxygen
reservoir
• Bag-valve-mask device
q Stethoscope
q Sphygmomanometer (child, adult, obese)
q Yankauer (Tonsil) suction
q Oropharyngeal airway
q Automated external defibrillator (AED)
 Required Emergency Drugs
Drug Dose Indication Administration/Route
Albuterol metered dose Mild asthmatic attack (mild 2-3 inhalations every 1-2
inhaler bronchospasm) minutes, up to three times if
needed
Aromatic ammonia Syncope Inhalant crushed and held four
inhalant to six inches under nose
Aspirin 165-325 mg 165-325 mg Angina, myocardial infarction One tablet chewed and
swallowed

Epinephrine 1:1,000 solution Severe bronchospasm: Intramuscular (IM) injection

Adults 0.3 mg 1. Severe asthmatic attack; resistant Subcutaneous (SC) injection
Children 0.15 mg to albuterol
2. Severe allergic reaction with
bronchospasm
Diphenhydramine 50 mg injectable Mild allergic reaction
25-50 mg tablet 50 mg intramuscularly
25-50 mg orally every 3-4
hours
Glucose - gel, orange Hypoglycemia If patient is conscious, ingest
juice, fruit juice
Glucagon 1 mg/dose Hypoglycemia IM injection

Nitroglycerin Angina Sublingual tablet: one every

five minutes up to three doses
Oxygen All medical emergencies except Nasal mask or prongs.
hyperventilation
 Required Emergency Drugs

D3 students are required to know dose and route of

each drug for the competency exam

IM (Intramuscular)
Oral SL (Sublingual)
SC (Subcutaneous)
 Oxygen Supplementation

Nasal cannula Simple face mask Nonrebreather

 NYUCD Medical Emergency Protocol (SATT)

Step 1 Step 2 Step 3 Step 4

911 for EMS

x89828 for Rapid Response

Stop Activate Emergency Think Treat

(Terminate Dental Tx) Response System (Diagnosis)

For competency exam, you

need to list a diagnosis

D3 students must use this format to answer questions on the competency exam
Include dose of any medication used on competency
 NYUCD Rapid Response Team Protocol

q Every medical emergency starts with stopping

dental Tx and calling for help
NYUCD
• Faculty responsible for dental care Security

• Security (x89828)
• Oral and maxillofacial surgery (called by
security)
q OMS faculty arrives and receives report from

FS
treatment team including

OM
• PMH
• Medications
• Treatment rendered
• Signs and symptoms
• Response to intervention
 Chest Pain

q Angina
q MI
 Chest Pain
Terminate dental Tx

Differential Diagnosis?

• Negative cardiac Hx • Positive cardiac Hx

• Noncardiac symptoms: burning, sharp, • Cardiac symptom: dull, constricting,
stabbing, prickling choking and/or crushing
• Pain is localized • Pain is diffuse

Noncardiac Differential Diagnosis: Angina/MI

1. Psychological: Hyperventilation 1. Position patient in semi-
2. GI: Dyspepsia (heartburn), GERD, gastric ulcer reclined posture
3. Musculoskeletal: Intercostal muscle spasms, rib 2. Oxygen
or chest muscle contusions 3. Vital signs

Tx for hyperventilation Continued…

Refer to MD or call EMS
 …Continued

Systolic BP?

>90 mm Hg <90 mm Hg or ≥30 mm Hg below baseline

Suspect angina Suspect MI

Nitroglycerin 0.4 mg SL

Pain persists Pain relieved

Repeat nitroglycerin SL Q3 minutes Defer dental Tx

up to 3 doses Refer to hospital/M.D.

If pain persists assume MI

1. Aspirin 160-325 mg
2. Call EMS
3. BLS if required
 Medications for Chest Pain

Aspirin
q Platelets play a major role in thrombus formation following
rupture of coronary artery plaque and are integrally involved in
the pathophysiology of ischemic heart disease
q Aspirin reduces coronary occlusion by platelet aggregation
q The patient should chew the aspirin to hasten absorption
q If the patient is nauseous, vomiting, or has active peptic ulcer
disease you can administer by rectal suppository

Nitroglycerin
q Nitroglycerin should not be administered in the presence of
hypotension (systolic BP <90 mm Hg) since it can further
decrease the mean arterial pressure
q Chest pain that is alleviated by nitroglycerin but returns should
be managed as though it were acute MI
 Loss of Consciousness

q Hypoglycemia
q Vasovagal
q Postural/Orthostatic hypotension
 Loss of Consciousness

1. Trendelenburg position
2. Oxygen
3. Vital signs

Check for breathing

Absent Present
Cardiac dysrhythmia Syncope
Cerebral vascular accident

Determine etiology
Call EMS
(hypoglycemia/vasovagal/postural)
Start BLS
Differential Diagnosis for Loss of Consciousness

Medical Emergency Characteristics

Hypoglycemia History of diabetes mellitus
Vasovagal syncope Hypotension and bradycardia
Postural (orthostatic) hypotension Supine to upright
 Vasovagal Syncope
Anxiety/Stress
q “Common faint”
q Predisposing factors éCatecholamines
• Psychogenic: fright, anxiety,
emotional stress, pain, sight êPeripheral Vascular Resistance
of blood
• Nonpsychogenic: erect sitting éPeripheral Blood Pooling
or standing posture, hunger,
exhaustion, poor physical êBP
condition, hot/humid
environment, males Bradycardia (inadequate
• Ages: 16-35 compensatory rise in HR)

êCerebral Blood Flow

 Postural (Orthostatic) Hypotension

q Inadequate peripheral vasoconstrictor activity when assuming

an upright position
• A disorder of the autonomic nervous system: a failure of the
baroreceptor reflex-mediated increase in peripheral vascular
resistance in response to positional changes
q Risk factors
• Drugs (antihypertensives, sedatives)
• Prolonged recumbency
• Pregnancy
• Advanced age
• Venous defects in the legs (varicose veins)
q Vital signs
• Decreased BP
• HR increases >20/min
 Treatment of Hypoglycemia
Signs of hypoglycemia?

Mild Moderate Severe

Hunger/Nausea/Mood Anxiety/Confusion/ Hypotension/Seizures/
change/Weakness Uncooperativeness/ Unconsciousness
Pallor/Perspiration/Tachycardia

Administer glucose by mouth Administer glucose by mouth BLS

Monitor vital signs / Oxygen Monitor vital signs / Oxygen

Before further dental Tx,
consult with MD, if unsure
whether or why hypoglycemia
has occurred
If symptoms do not rapidly
improve, administer 50 mL
50% glucose or 1 mg
glucagon IV or IM
Administer 50 mL 50%
glucose IV or IM or 1 mg
glucagon
Monitor vital signs / Oxygen

Consult MD before further dental Tx Transport to ER

 Treatment of Vasovagal Syncope &
Postural (Orthostatic) Hypotension
1. Terminate dental Tx
2. Trendelenburg position
3. BLS
4. Oxygen
5. Vital signs
6. Ammonia inhalant
7. Call EMS if loss of consciousness is >5 minutes or if recovery
is >20 minutes
8. Discharge the patient home once the vital signs have returned
to preoperative levels and are stable
9. For patients with postural hypotension, slowly return the
patient to the sitting position
 Seizures

Differential Diagnosis
q Epilepsy
q Local anesthesia overdose
q Hypoglycemia
q Loss of consciousness
 Treatment of Seizures
Acute Management
1. Terminate dental Tx
2. Supine position
3. Prevent tongue biting (gauze-wrapped tongue blade)
4. Protect patient from nearby objects

After Seizure

Patient is unconscious Patient is conscious

1. Place patient on side, and suction airway 1. Suction airway if necessary
2. Monitor VS 2. Monitor VS
3. BLS if necessary (apnea >30 seconds) 3. Oxygen
4. Oxygen 4. Observe patient 30 mins-1 hour
5. Call EMS if this is the first seizure, seizure 5. Have patient escorted home if fully
lasts more than 2 minutes, or multiple seizures alert or taken to ER (call EMS)
lasting 5 minutes
 Treatment of Seizures: Airway Protection

If the patient vomits or seems to be having problems keeping

secretions out of the airway:
1. The patient's head must be positioned to the side to allow
obstructing materials to drain out of the mouth
2. Apply suction
 Shortness of Breath

Differential Diagnosis
q Hyperventilation
q Foreign body aspiration
q Asthma
 Shortness of Breath (Conscious Patient)

Upright position for comfort

Oxygen
Vital signs

Review medical history

NEGATIVE POSITIVE
Hyperventilation Asthma
Foreign body aspiration
 Treatment of Airway Obstruction (Choking)
Assess Severity

Severe Airway Obstruction Mild Airway Obstruction

(Ineffective cough, “crowing”, absent (Effective cough)
voice sounds, cyanosis)
Supine Sitting
position posture
Unconscious Conscious Ø Encourage cough
Abdominal thrusts 5 Back blows Ø Continue to check for
No improvement deterioration to ineffective
Turn of side & cough or relief of obstruction
finger sweep if 5 Abdominal thrusts
object is visible (Heimlich maneuver)

CXR
Abdominal X-ray
Start BLS; 911
Advanced airway techniques (laryngoscopy, cricothyrotomy)
 Hyperventilation
q The most frequent cause of respiratory difficulty in the dental
setting
q Acute anxiety is the most common predisposing factor
q Most common for patients 15 to 40 years of age
q Characteristics
• Neurologic: dizziness, tingling or numbness of fingers, toes,
or lips (i.e., respiratory alkalosis, hypocarbia, hypocapnea),
syncope is rare
• Respiratory: increased rate and depth of breaths
(hyperpnea), feeling of shortness of breath, chest pain,
xerostomia
• Cardiovascular: palpitations, tachycardia, elevated BP,
precordial pain
• Musculoskeletal: myalgia, muscle spasm, tremor, tetany
• Psychologic: anxiety, tension, nightmares
 Treatment of Hyperventilation

1. Terminate dental Tx
2. Upright position
3. Reassure and calm patient
4. Slow deep breaths in a small bag or
cupped hands
5. If symptoms persist or worsen, administer
diazepam 10 mg IM or titrate slowly
intravenously until anxiety is relieved; or
administer midazolam 5 mg IM or titrate
slowly intravenously until anxiety if relieved
6. Monitor vital signs
 Clinical Presentation of Asthma
Mild to Moderate
q Wheezing (audible with or without stethoscope)
q Dyspnea (i.e., labored breathing)
q Tachycardia
q Coughing
q Anxiety

Severe
q Intense dyspnea, flaring of the nostrils and use of accessory muscles of
respiration
q Cyanosis of mucous membranes and nail beds
q Minimal breath sounds on auscultation
q Difficulty speaking
q Flushing of the face
q Extreme anxiety
q Mental confusion
q Diaphoresis

Asthma is often worse at night and in the early morning hours

 Treatment of Acute Asthma
Patient with shortness of breath or wheezing
1. Terminate all dental Tx
2. Position patient in fully upright sitting posture
3. Albuterol metered dose inhaler (2-3 inhalations every 1-2 minutes, up to three times if needed)
4. Oxygen
5. Monitor vital signs

Mild Asthma Attack Severe Asthma Attack

Signs/Symptoms Relieved Signs/Symptoms Continue

6.Monitor recovery 6. Epinephrine 0.3 mg (0.3 mL of

7.Discontinue dental Tx until patient 1:1000 solution) IM or SC
is evaluated by MD 7. Monitor vital signs

Signs/Symptoms Continue

8. Call EMS
 Perioperative Management of Asthma
q Well-controlled asthma does not pose a significant risk
q Defer dental Tx if patient has wheezing or upper respiratory
tract infection
q What are the precipitating factors (e.g., emotional distress,
exercise, chemical irritants, cold air, viral infections, aspirin),
frequency and severity of attacks (e.g., ER visits), medications
used and response to medications?
q Patient’s own metered-dose inhaler (MDI) bronchodilator
should be on hand at each visit
q If patient has been chronically taking corticosteroids and
requires extensive surgery, provide prophylaxis for adrenal
insufficiency (Solu-Cortef 100 mg)
q Avoid the use of NSAIDs in patients who have attacks
associated with the use of aspirin
 Preventative Management of Asthma
q If anxiety is a trigger, use anxiety-reduction protocol
• Appointments in late morning
• Keep appointments as short as possible (spread lengthy
procedures over several visits)
• Nitrous oxide is NOT a respiratory depressant nor an
irritation to the tracheobronchial tree
• Promethazine (Phenergan®) and diphenhydramine
(Benadryl®) have sedative, antiemetic and antihistaminic
properties
q Consult MD about prophylaxis: cromolyn sodium, inhaled
corticosteroid, leukotriene modifiers, methylxanthines, long-
acting beta agonists with corticosteroid (e.g., Advair®,
Symbicort®)
q Rescue inhalers (e.g., short-acting beta agonists, albuterol) are
not routinely recommended for prophylaxis
Allergic Reaction & Anaphylaxis
 Allergy
q Signs and symptoms
• Pruritus (itching)
• Hives
• Urticaria (smooth, slightly elevated patches of skin)
• Erythema
• Facial flushing
• Nausea and vomiting
q Treatment
• Monitor vital signs for systemic involvement (anaphylactic
shock)
• Diphenhydramine 50 mg IV or IM followed by oral dose 50
mg Q6-8hr
 Anaphylaxis
q Signs and symptoms
• Same as allergy plus
─ Respiratory: wheezing, laryngospasm, dyspnea, stridor,
cyanosis
─ Cardiovascular: hypotension, tachycardia, arrhythmia
q Classification
• One organ system = Localize anaphylaxis (i.e., bronchial
asthma)
• Generalized (systemic) = Anaphylactic shock (i.e.,
hypotension)
 Treatment of Anaphylaxis
q Supine/Elevate legs for unconscious patient
q BLS
q Oxygen
q Monitor vital signs
q Call EMS
q Medications
• Diphenhydramine – Mild allergic reaction
• Epinephrine 0.3 mg (0.3 mL of 1:1000) – Severe allergic
reaction (bronchospasm)
─ Route depends on severity (SC, IM)
 Medical Emergency Competency

Answering questions for the Medical Emergency Competency

should be based on the information contained in this manual