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Management Of Medical Emergencies In The Dental Office

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. Management of Medical Emergencies.

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Management Of Medical Emergencies In The Dental Office

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  1. 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

  2. Management of Medical Emergencies • Medical emergencies can and do happen • Advances in medicine • Longer lifespan • Multiple medications • Medically compromised • Longer appointments

  3. Incidence • A survey done in the 90’sshowed that, over a 10 year period, 90% of dentists have encountered at least one medical emergencies.

  4. Types

  5. Management of Medical Emergencies Basic Life Support Advanced Life Support

  6. 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

  7. Management Of Medical Emergencies • Recognition • Prevention • Preparation • Basic life support (BLS) • Cardiopulmonary resuscitation (CPR) • Specific medical emergencies

  8. Prevention • IS THE BEST TREATMENT Know your patient Never treat a STANGER

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

  10. Prevention • Medical History • Physical Evaluation • Vital Signs • Dialogue History • Determination of Medical Risk • Stress Reduction

  11. Prevention MEDICAL HISTORY • Review • Update • Medication • Medical consultation

  12. Prevention PHYSICAL EVALUATION • Length of time since last evaluation • Vital signs • Visual inspection of patients • Referral to physician

  13. Blood pressure Pulse rate Respiratory rate Temperature Height Weight Prevention VITAL SIGNS

  14. Prevention DIALOGUE HISTORY • Putting it all together • Check accuracy of medical history • Recognize anxiety

  15. 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?

  16. Determination Of Medical Risk American Society ofAnesthesiology Physical Status ClassificationSystem

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

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

  19. 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 Elective Dental Treatment is not Contraindicated Treatment Modification is Required - Reduce Stress - Sedation - Short Appointments ASA III

  20. 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 Elective dental care should be postponed Emergency dental care only Rx only to control pain and infection Other treatment in hospital (I&D, extraction) ASA IV

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

  22. Prevention STRESS REDUCTION • Premedication • Sedation • Pain control (intra and post-op) • Early appointments • Short appointments

  23. Preparation • Team Effort • BLS for all office personnel • CPR for all office personnel • Emergency drills • Emergency phone numbers (911) • Emergency equipment

  24. BASIC LIFE SUPPORT(BLS)CARDIOPULMONARY RESUCITATION(CPR)

  25. 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

  26. 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

  27. 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.

  28. Management of Medical EmergenciesAntibiotic 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

  29. Management of Medical EmergenciesAntibiotic Prophylaxis Prophylactic Regimen for Dental Procedures Allergic to Penecillin Adult Children ORALLY 1 HOUR BEFORE PROCEDURE

  30. Management of Medical EmergenciesAntibiotic 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

  31. Management of Medical EmergenciesAntibiotic Prophylaxis • Amoxicillin vs. Penecillin • 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 EmergenciesAntibiotic 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

  33. Management of Medical EmergenciesAntibiotic Prophylaxis • Patient already taking antibiotic used for prophylaxis: • Select an antibiotic from a different class, rather than increasing the dosage • 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

  34. Management of Medical EmergenciesAntibiotic Prophylaxis Prophylaxis for dental patients with TOTAL JOINT REPLACEMENT

  35. Management of Medical EmergenciesAntibiotic 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

  36. Management of Medical EmergenciesAntibiotic 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

  37. Management of Medical EmergenciesAntibiotic 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

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