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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.com – PowerPoint PPT presentation

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Title: Management of Sedation Emergencies Patrick D. McCarty, DDS


1
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
2
Preventing Emergencies
  • Thorough medical history
  • Baseline vital signs
  • Continuous monitoring
  • PRECORDIAL stethoscope
  • Local anesthesia aspiration slow injection
  • BLS/CPR training - all office personnel

3
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

4
Basic Life Support Principles
  • Assessment
  • Call for help
  • Position
  • Airway
  • Breathing
  • Circulation
  • Cardiopulmonary resuscitation

5
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

6
Syncope
  • Causes
  • Fear and anxiety
  • Orthostatic/postural hypotension
  • Cardiac conduction defects

7
Syncope
  • Prevention
  • Medical history
  • Stress reduction protocol
  • Patient position
  • Oxygen

8
Syncope
  • Symptoms
  • Pale ashen-gray appearance
  • Sweaty
  • Nausea
  • Eyes dilate
  • Convulsive movements

9
Syncope
  • Treatment
  • POSITION SUPINE with FEET ELEVATED
  • Administer 100 OXYGEN
  • MONITOR VITALS respiration, pulse, blood
    pressure, and oxygen saturation
  • Loosen tight clothing

10
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

11
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

12
Hyperventilation Syndrome
  • Cause
  • Fear and anxiety
  • Most common in women between the ages of 15 and 40

13
Hyperventilation Syndrome
  • Prevention
  • Past hyperventilation history
  • Recognition and management of anxiety
  • Stress reduction protocol

14
Hyperventilation Syndrome
  • Symptoms
  • Feeling of suffocation
  • Tightness in chest
  • Fast respiration
  • Giddy
  • Light-headedness
  • Tingling or paresthesia
  • Color usually good
  • Trembling
  • Carpopedal spasm

15
Hyperventilation Syndrome
  • Treatment
  • POSITION comfortably
  • DO NOT GIVE OXYGEN !!!!!!!
  • Reassure patient

16
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)

17
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.

18
Airway Obstruction
  • Causes
  • Dental objects (head of handpiece, mouth mirror,
    endodontic file, crown, extracted tooth, amalgam,
    or calculus)

19
Airway Obstruction
  • Prevention
  • Use rubber dam for restorative and endodontic
    procedures
  • Use "loose" throat screen for extraction or
    seating crowns
  • (4x4 gauze)

20
Airway Obstruction
  • Symptoms
  • Noisy breathing is partial obstruction
  • Victim gasping for breath with great effort

21
Airway Obstruction
  • Retraction of suprasternal notch and/or
    intercostal regions during attempted inspiration
    (complete obstruction)
  • Patient unable to speak (universal sign hand at
    throat)

22
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.

23
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.)

24
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

25
Aspiration of Vomitus
  • DEFINITION aspiration of vomitus into pulmonary
    tract while protective reflexes are not intact
    (unconscious)
  • Sixty-two percent mortality

26
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

27
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)

28
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

29
Bradycardia
  • DEFINITION heart rate slower than 60/min, from
    unexplained cause
  • (Must understand heart rate is age dependent)

30
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

31
Bradycardia
  • Prevention
  • Medical history
  • Stress reduction protocol

32
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

33
Seizure
  • DEFINITION convulsions resulting from excessive
    neuronal discharge which spreads throughout the
    brain

34
Seizure
  • Causes
  • Spontaneously occurring (i.e. Epilepsy)
  • Toxic effect of medications on the CNS (i.e.
    lidocaine)
  • Metabolic disorders (i.e. Hypoglycemia)

35
Seizure
  • Prevention
  • Medical history
  • Stress reduction protocol

36
Seizure
  • Treatment
  • Position supine
  • Prevent injury use padded tongue blade as mouth
    prop (some will disagree)
  • Administer 100 OXYGEN
  • Reassure patient

37
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

38
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)

39
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

40
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!)
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