Management of Sedation Emergencies Patrick D. McCarty, DDS

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Management of Sedation Emergencies
Patrick D. McCarty, DDS Dentist
Anesthesiologist McCarty Anesthesiology,
LLC Cambridge, MA 02141 617.913.3363 www.zzzdmd.co
m mccarty.dental.anesthesia_at_gmail.com
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Preventing Emergencies

• Thorough medical history
• Baseline vital signs
• Continuous monitoring
• PRECORDIAL stethoscope
• Local anesthesia aspiration slow injection
• BLS/CPR training - all office personnel

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Medical History

• Biographical data
• Chief complaint
• History of present illness
• Past medical history
• Family history
• Social history

• Medications
• Allergies
• Review of systems
• Physical exam
• Laboratory values
• Assessment/plan

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Basic Life Support Principles

• Assessment
• Call for help
• Position
• Airway

• Breathing
• Circulation
• Cardiopulmonary resuscitation

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Syncope(Hypotension)

• DEFINITION massive peripheral vasodilation
  leading to low cardiac output resulting in
  decreased cerebral blood flow which often results
  in transient loss of consciousness
• Most common emergency

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Syncope

• Causes
• Fear and anxiety
• Orthostatic/postural hypotension
• Cardiac conduction defects

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Syncope

• Prevention
• Medical history
• Stress reduction protocol
• Patient position
• Oxygen

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Syncope

• Symptoms
• Pale ashen-gray appearance
• Sweaty
• Nausea
• Eyes dilate
• Convulsive movements

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Syncope

• Treatment
• POSITION SUPINE with FEET ELEVATED
• Administer 100 OXYGEN
• MONITOR VITALS respiration, pulse, blood
  pressure, and oxygen saturation
• Loosen tight clothing

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Syncope

• Treatment (continued)
• Cool, moist towel to patients forehead (provides
  stimulation)
• AMMONIA (if unconscious)
• If hypotension persists, EPINEPHRINE (110,000)
• 0.01 mg/kg IV/IM
• If bradycardia, ATROPINE 0.01 mg IV/IM

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Hyperventilation Syndrome

• DEFINITION anxiety induced increased
  ventilation resulting in a reduction of the
  carbon dioxide tension of the blood, may
  typically result in Carpopedal spasm

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Hyperventilation Syndrome

• Cause
• Fear and anxiety
• Most common in women between the ages of 15 and 40

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Hyperventilation Syndrome

• Prevention
• Past hyperventilation history
• Recognition and management of anxiety
• Stress reduction protocol

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Hyperventilation Syndrome

• Symptoms
• Feeling of suffocation
• Tightness in chest
• Fast respiration
• Giddy
• Light-headedness

• Tingling or paresthesia
• Color usually good
• Trembling
• Carpopedal spasm

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Hyperventilation Syndrome

• Treatment
• POSITION comfortably
• DO NOT GIVE OXYGEN !!!!!!!
• Reassure patient

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Hyperventilation Syndrome

• Rebreathing in paper bag, head rest cover or your
  hands
• VERSED 1-2 mg IV/IM (only in most severe cases.
  Titrate to relaxation)

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Airway Obstruction

• DEFINITION partial or complete obstruction of
  the airway. Frequently caused by object falling
  into the oral pharynx. Most serious are objects
  entering the larynx or trachea.

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Airway Obstruction

• Causes
• Dental objects (head of handpiece, mouth mirror,
  endodontic file, crown, extracted tooth, amalgam,
  or calculus)

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Airway Obstruction

• Prevention
• Use rubber dam for restorative and endodontic
  procedures
• Use "loose" throat screen for extraction or
  seating crowns
• (4x4 gauze)

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Airway Obstruction

• Symptoms
• Noisy breathing is partial obstruction
• Victim gasping for breath with great effort

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Airway Obstruction

• Retraction of suprasternal notch and/or
  intercostal regions during attempted inspiration
  (complete obstruction)
• Patient unable to speak (universal sign hand at
  throat)

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Airway Obstruction

• Treatment (HEIMLICH maneuver)
• POSITION (if conscious) behind patient, wrap your
  arms around their abdomen, one fist placed into
  abdomen (thumb side first) other hand over fist.

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Airway Obstruction

• Administer ABDOMINAL THRUSTS brisk inward and
  upward delivery back blows are no longer
  recommended in adults or children older than one
  year of age
• Remove foreign body (use finger, suction, etc.)

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Airway Obstruction

• TREATMENT (continued)
• Airway maneuver
• A) head-tilted
• B) displace mandible forward
• C) retract lower lip to allow breathing
  between lips
• D) attempt to ventilate

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Aspiration of Vomitus

• DEFINITION aspiration of vomitus into pulmonary
  tract while protective reflexes are not intact
  (unconscious)
• Sixty-two percent mortality

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Aspiration of Vomitus

• Diagnosis
• High index of suspicion (vomiting while patient
  has altered protective reflexes)
• Auscultation of chest
• X-ray examination
• Arterial blood gases
• Elevated temperature within 12 hours

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Aspiration of Vomitus

• Prevention
• Keep patient CONSCIOUS
• Include anti-emetic in sedation medications
• NPO for at least 6 hours (gen anesth)
• High volume suction (especially for sedation or
  general anesthesia)

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Aspiration of Vomitus

• Treatment
• Position TRENDELENBURG
• Roll onto RIGHT SIDE (helps confine aspirate to
  right lung)
• Suction VOMITUS
• Administer 100 OXYGEN
• DEXAMETHASONE 10 mg IV / IM or SOLU-CORTEF 50 mg
  IV
• Transport to emergency care facility

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Bradycardia

• DEFINITION heart rate slower than 60/min, from
  unexplained cause
• (Must understand heart rate is age dependent)

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Bradycardia

• Causes
• Increased Vagal tone as in sinus bradycardia.
  (Pressure on eyes or pulling on tongue can also
  be cause of increased Vagal tone)
• Block in the cardiac conduction system

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Bradycardia

• Prevention
• Medical history
• Stress reduction protocol

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Bradycardia

• Treatment
• Position comfortable
• Reassure patient
• Give 100 OXYGEN via loose mask or nasal cannula
• Atropine 0.02 mg/kg IV/IM (Max 0.5 - 1 mg)
• Use basic life support if unconscious

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Seizure

• DEFINITION convulsions resulting from excessive
  neuronal discharge which spreads throughout the
  brain

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Seizure

• Causes
• Spontaneously occurring (i.e. Epilepsy)
• Toxic effect of medications on the CNS (i.e.
  lidocaine)
• Metabolic disorders (i.e. Hypoglycemia)

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Seizure

• Prevention
• Medical history
• Stress reduction protocol

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Seizure

• Treatment
• Position supine
• Prevent injury use padded tongue blade as mouth
  prop (some will disagree)
• Administer 100 OXYGEN
• Reassure patient

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Seizure

• If seizure recurs VERSED 1-2 mg IV/IM, May
  repeat in 2 min one time
• If seizure not controlled, call 911
• DISCONTINUE all further dental treatment for that
  day

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Stress Reduction Protocol

• Patient should sleep well the night before the
  appointment
• Use pre-op medication
• Use intraoperative sedation if indicated (PO / IM
  / IV / INHALATIONAL)

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Stress Reduction Protocol

• Consider morning appointment (functional reserve
  is usually highest in the morning)
• Consider limiting the length of the treatment to
  avoid exceeding the patients level of physical or
  emotional tolerance

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Stress Reduction Protocol

• Consider post-op control of pain and anxiety
• Schedule appointment when the DOCTOR will be
  available on call for post-op problems
• Telephone the patient in the evening after the
  appointment to provide emotional support (great
  practice builder, too!)