Medical Emergencies in the Dental Office

Cover
Half Title Page
Title Page
Copyright
Dedication
Foreword to the Sixth Edition (Previously published)
Preface to Eighth Edition
Acknowledgments
Contents
Part One: Prevention
1. Introduction
Morbidity
Death or Permanent Brain Damage
The State of Preparation for the Recognition and Management of Medical Emergencies in Dental Offices
Risk Factors
Increased Numbers of Older Patients
Medical Advances
Longer Appointments
Increased Drug Usage
Classification of Life-Threatening Situations
Outline of Specific Emergency Situations
References
2. Prevention
Evaluation Goals
Physical Evaluation
Medical History Questionnaire
University of the Pacific’s Medical History Questionnaire
Medical History Questionnaire
Section II, Have You Experienced
13 Sinus problems?
Section III, Do You Have, or Have You Had
35 Asthma, tuberculosis, emphysema, other lung disease?
Section IV, Do You Have, or Have You Had
Section V, Are You Taking
Section VI, Women Only
Section VII, All Patients
Medical History Questionnaire
Physical Examination
Vital Signs
Blood Pressure
Guidelines for Clinical Evaluation
Heart Rate and Rhythm
Guidelines for Clinical Evaluation
Respiratory Rate and Oxygen Saturation
Guidelines for Clinical Evaluation
Temperature
Guidelines for Clinical Evaluation
Height and Weight
Guidelines for Clinical Evaluation
Body Mass Index
Interpretation of BMI
Visual Inspection
Additional Evaluation Procedures
Dialogue History: Diabetes
Dialogue History
Dialogue History: Angina
Recognition of Dental Fear and Anxiety
Psychological Examination
Medical History Questionnaire
Dental Anxiety Questionnaire
Observation
Determination of Medical Risk
American Society of Anesthesiologists Physical Status Classification System
ASA 1
ASA 2
ASA 3
ASA 4
ASA 5
Medical Consultation
Stress-Reduction Protocol
Recognition of Medical Risk and Anxiety
Medical Consultation
Premedication
Appointment Scheduling
Minimized Waiting Time
Vital Signs (Preoperative and Postoperative)
Sedation During Treatment
Adequate Pain Control During Treatment
Duration of the Dental Treatment
Postoperative Control of Pain and Anxiety
References
3. Preparation
General Information
Geographic Requirements for Emergency Training
Office Personnel
Training
Basic Life Support
Defibrillation
Team Management
Duties of Team Member #1
Duties of Team Member #2
Duties of Team Member #3
Emergency Practice Drills
Office Preparation: Seeking Emergency Medical Assistance
Whom to Call
Whom to Call
When to Call
Emergency Drugs and Equipment
Proprietary Versus Homemade Emergency Drug Kits
Emergency Drug Kits
Components of an Emergency Kit
Administration of Injectable Drugs
Parenteral Drug Administration
Module One: Essential Emergency Drugs and Equipment
Essential Injectable Drugs
Primary Injectable: Drug for Acute Allergic Reaction (Anaphylaxis)
Drug of Choice
Drug Class
Alternative Drug
Proprietary
Therapeutic Indications
Side Effects, Contraindications, and Precautions
Availability
Dose
Suggested for Emergency Kit
Primary Injectable: Drugs for a Non-Life-Threatening Allergic Reaction
Drug of Choice
Proprietary
Drug Class
Alternative Drug
Therapeutic Indications
Side effects, contraindications, and precautions
Availability
Suggested for Emergency Kit
Essential Noninjectable Drugs
Primary Noninjectable: Oxygen (O2)
Drug of Choice
Drug Class
Alternative drug
Proprietary
Therapeutic Indications
Side Effects, Contraindications, and Precautions
Availability
Suggested for Emergency Kit
Primary noninjectable: vasodilator
Drug of Choice
Proprietary
Drug Class
Alternative Drug
Therapeutic Indications
Side Effects, Contraindications, and Precautions
Availability
Suggested for Emergency Kit
Primary Noninjectable: Bronchodilator
Drug of Choice
Proprietary
Drug Class
Alternative Drug
Therapeutic Indications
Side Effects, Contraindications, and Precautions
Availability
Suggested for Emergency Kit
Primary Noninjectable: Antihypoglycemic
Drug of Choice
Drug Class
Alternative Drug
Proprietary
Therapeutic Indications
Side Effects, Contraindications, and Precautions
Availability
Suggested for emergency kit
Primary noninjectable: antiplatelet
Drug of Choice
Drug Class
Alternative Drug
Therapeutic Indications
Side Effects, Contraindications, and Precautions
Availability
Suggested for Emergency Kit
Primary Noninjectable: Opioid-Receptor Antagonist
Drug of Choice
Drug Class
Alternative Drug
Therapeutic Indication
Side Effects, Contraindications, and Precautions
Availability
Nasal spray: Narcan nasal spray – 4.0 mg/0.1 mL actuation; 2 sprays per bottle (Fig. 3.14B)
Suggested for Emergency Kit
Essential Emergency Equipment
O2 Delivery System
Positive Pressure
Bag-Valve-Mask Device
Pocket Mask
Suggested for Emergency Kit
Automated External Defibrillator (AED)
Suggested for Emergency Kit
Suggested for Emergency Kit
Syringes
Suggested for an Emergency Kit
Suction and Aspirating Apparatus
Suggested for Emergency Kit
Tourniquets
Suggested for Emergency Kit
Magill Intubation Forceps
Suggested for Emergency Kit
Module Two: Secondary (Nonessential) Emergency Drugs and Equipment
Secondary Injectable Drugs
Secondary Injectable: Anticonvulsant
Drug of Choice
Proprietary
Drug Class
Alternative Drug
Therapeutic Indications
Side Effects, Contraindications, and Precautions
Availability
Suggested for Emergency Kit
Secondary Injectable: Analgesic
Drug of Choice
Proprietary
Drug Class
Alternative Drug
Therapeutic Indications
Side Effects, Contraindications, and Precautions
Availability
Suggested for Emergency Kit
Secondary Injectable: Vasopressor
Drug of Choice
Proprietary
Drug Class
Alternative Drug
Therapeutic Indications
Side Effects, Contraindications, and Precautions
Availability
Suggested for Emergency Kit
Secondary Injectable: Antihypoglycemic
Drug of Choice
Proprietary
Drug Class
Alternative Drug
Therapeutic Indications
Side Effects, Contraindications, and Precautions
Availability
Suggested for Emergency Kit
Secondary Injectable: Corticosteroid
Drug of Choice
Proprietary
Drug Class
Alternative Drug
Therapeutic Indications
Side Effects, Contraindications, and Precautions
Availability
Suggested for Emergency Kit
Secondary Injectable: Antihypertensive
Drug of Choice
Proprietary
Drug Class
Alternative Drug
Therapeutic Indication
Side Effects, Contraindications, and Precautions
Availability
Suggested for Emergency Kit
Secondary Injectable: Parasympathetic Blocking Agent
Drug of Choice
Drug Class
Alternative Drug
Proprietary
Therapeutic Indications
Side Effects, Contraindications, and Precautions
Availability
Suggested for Emergency Kit
Secondary Noninjectable Drugs
Secondary Noninjectable: Respiratory Stimulant
Drug of Choice
Proprietary
Drug Class
Alternative Drug
Therapeutic Indications
Side Effects, Contraindications, and Precautions
Availability
Suggested for Emergency Kit
Secondary Noninjectable: Antihypertensive
Drug of Choice
Proprietary
Drug Class
Alternative Drug
Therapeutic Indications
Side Effects, Contraindications, and Precautions
Availability
Suggested for Emergency kit
Secondary Emergency Equipment
Oropharyngeal and Nasopharyngeal Airways
Suggested for Emergency Kit
Advanced Airway Devices
Laryngeal Mask Airway
Endotracheal Intubation
Suggested for the Emergency Kit
Scalpel or Cricothyrotomy Device
Suggested for Emergency Kit
Module Three: Advanced Cardiovascular Life Support (ACLS)
ACLS Essential Drugs
ACLS Essential:
Drug of Choice
Proprietary
Drug Class
Alternative Drug
Therapeutic indications
Side Effects, Contraindications, and Precautions
Availability
Suggested for Emergency Kit
ACLS essential: O2
Drug of Choice O2
Proprietary
Drug Class
Alternative Drug
ACLS Essential: Antidysrhythmic
Drug of Choice
Proprietary
Drug Class
Alternative Drug
Therapeutic Indications
Side Effects, Contraindications, and Precautions
Availability
Suggested for Emergency Kit
ACLS Essential: Symptomatic Bradycardia
Drug of Choice
Proprietary
Drug Class
Alternative Drug
Therapeutic Indications
Side Effects, Contraindications, and Precautions
Availability
Suggested for Emergency Kit
ACLS Essential: Paroxysmal Supraventricular Tachycardia (PSVT)
Drug of Choice
Proprietary
Drug Class
Alternative Drug
Therapeutic Indications
Side Effects, Contraindications, and Precautions
Availability
Suggested for Emergency Kit
Module Four: Antidotal Drugs
Antidotal Drugs
Antidotal Drug:
Drug of Choice
Proprietary
Drug Class
Alternative Drug
Therapeutic Indications
Side Effects, Contraindications, and Precautions
Availability
Suggested for Emergency Kit
Antidotal Drug: Anti-Emergence Delirium Drug
Drug of Choice
Proprietary
Drug Class
Alternative Drug
Therapeutic Indications
Side Effects, Contraindications, and Precautions
Availability
Suggested for Emergency Kit
Antidotal Drug: Vasodilator
Drug of Choice
Proprietary Name
Drug Class
Alternative Drug
Therapeutic Indications
Side Effects, Contraindications, and Precautions
Availability
Suggested for Emergency Kit
Two 1-mL ampules
Organization of the Emergency Drug Kit
IM Drug Administration
IV Drug Administration
References
4. Legal Considerations
Modern Liability Insurance Crises
Theories of Liability
Statute Violations
Contract Law
Criminal Law
Tort Law
Duty
Breach of Duty
Causation
Damage
Reasonableness
Consent
Statute of Limitations
Emergency Situations
Standard of Care During Emergencies
Consent During Emergencies
Defining an Emergency
Emergency Rescues—Good Samaritan Statutes
Relationship Between the Doctor and an Emergency Patient
Foreseeability
Limiting Liability for Emergencies
Prevention and Preparation
Poor Decisions
Respondeat Superior
Community Standards
Professional Relationships
Collegiality
Philosophical Aspects of Treating Emergencies
Is a dentist absolutely required to manage a potentially life-threatening emergency?
Is calling 9-1-1 sufficient to fulfill this responsibility during a rescue?
What is the dentist’s responsibility when another provider with more emergency expertise arrives?
Is a dentist legally required to maintain an emergency drug kit and/or CPR certification?
What drugs should be contained in an emergency kit?
What is the dentist’s ultimate responsibility during a medical emergency in the office?
References
Part Two: Unconsciousness
5. Unconsciousness: General Considerations
Predisposing Factors
Prevention
Clinical Manifestations
Pathophysiology
Inadequate Cerebral Circulation
Oxygen Deprivation
General or Local Metabolic Changes
Actions on the Central Nervous System
Psychic Mechanisms
Management
Recognition of Unconsciousness
Step 1: Assessment of Consciousness
Step 2: Termination of the Dental Procedure
Step 3: Summoning of Help
Management of the Unconscious Patient
Step 4: P—Position Victim
Step 5: C—Assess Circulation
Step 6: A—Assess and Open the Airway
Head Tilt–Chin Lift Technique
Jaw-Thrust Technique (If Necessary)
Step 7a: B—Assess Airway Patency and Breathing
Step 7b: B—Rescue Breathing (If Necessary)
Exhaled Air Ventilation
Atmospheric Air Ventilation
Airway Adjuncts
O2-Enriched Ventilation
Step 8: D—Definitive Management
References
6. Vasodepressor Syncope
Predisposing Factors
Prevention
Positioning
Anxiety Relief
Dental Therapy Considerations
Clinical Manifestations
Presyncope
Syncope
Postsyncope (Recovery)
Pathophysiology
Presyncope
Syncope
Recovery
Management
Presyncope
Step 1: P (Position)
Step 2: C → A → B (Circulation-Airway-Breathing)
Step 3: D (Definitive Care)
Syncope
Step 1: Assessment of Consciousness
Step 2: Activation of the Dental Office Emergency System
Step 3: P (Position)
Step 4: C → A → B (Basic Life Support, as Needed)
Step 5: D (Definitive Care)
Step 5a: administration of O2
Step 5b: monitoring of vital signs
Step 5c: additional procedures
Delayed Recovery
Postsyncope
ADDENDUM Case Report #1—Vasodepressor Syncope
ADDENDUM Case Report #2—Vasodepressor Syncope
References
7. Postural Hypotension
Predisposing Factors
Drug Administration and Ingestion
Prolonged Recumbency and Convalescence
Inadequate Postural Reflex
Pregnancy
Age
Venous Defects in the Legs
Recovery from a Sympathectomy for High Blood Pressure
Addison’s Disease
Physical Exhaustion and Starvation
Chronic Postural Hypotension (Shy-Drager Syndrome)
Prevention
Medical History Questionnaire
Section V, Are You Taking
Section II, Have You Experienced
Physical Examination
Dental Therapy Considerations
Dental Therapy Considerations: Postural Hypotension
Clinical Manifestations
Pathophysiology
Normal Regulatory Mechanisms
Postural Hypotension
Management
Step 1: Assessment of Consciousness
Step 2: Activation of the Office Emergency System
Step 3: P (Position)
Step 4: C → A → B (Circulation-Airway-Breathing)
Step 5: D (Definitive Care)
Step 5a: Administration of O2
Step 5B: Monitoring of Vital Signs
Step 6: Subsequent Management
Step 6a: Delayed Recovery
Step 7: Discharge
References
8. Acute Adrenal Insufficiency
Predisposing Factors
Prevention
MEDICAL
Section V, Are You Taking
Section IV, Do You Have or Have You Had
Dialogue History
Dental Therapy Considerations
Glucocorticosteroid Coverage
Stress-reduction Protocol
Additional Considerations
Clinical Manifestations
Pathophysiology
Normal Adrenal Function
Adrenal Insufficiency
Management
Conscious
Step 1: Termination of Dental Treatment
Step 2: P (Position)
Step 3: C → A → B (Circulation-Airway-Breathing- [BLS]), As Needed
Step 4: D (Definitive Care)
Step 4a: Monitoring of Vital Signs
Step 4b: Summoning of Emergency Medical Assistance
Step 4c: Emergency Kit and Oxygen (O2)
Step 4d: Administration of Glucocorticosteroid
Step 5: Additional Management
Unconscious Patient
Step 1: Recognition of Unconsciousness
Step 2: P (Position)
Step 3: C → A → B (Circulation-Airway-Breathing-[BLS]), As Needed
Step 4: D (Definitive Care)
Step 4a: Emergency Drugs and O2
Step 4b: Summoning of Emergency Medical Assistance
Step 4c: Evaluation of Medical History
Step 4d: Administration of Glucocorticosteroid
Step 4e: Additional Drug Therapy
Step 5: Transfer to Hospital
References
9. Unconsciousness: Differential Diagnosis
Age of Patient
Circumstances Associated With Loss of Consciousness
Position of the Patient
Presyncopal Signs and Symptoms
No Clinical Symptoms
Pallor and Cold, Clammy Skin
Tingling and numbness of the extremities
Headache
Chest “pain”
Breath odor
Tonic-clonic movements and incontinence
Heart rate and blood pressure
Duration of unconsciousness and recovery
Part Three: Respiratory Distress
10. Respiratory Distress: General Considerations
Predisposing Factors
Prevention
Clinical Manifestations
Pathophysiology
Management
Step 1: Recognition of Respiratory Distress
Step 2: Discontinue the Dental Procedure
Step 3: P (Position the Patient)
Step 4: C → A → B (Circulation-Airway-Breathing) BLS, as Required
Step 5: D (Definitive Care)
Step 5a: Monitoring of Vital Signs
Step 5b: Definitive Management of Anxiety
Step 5c: Definitive Management of Respiratory Distress
Step 5d: Activate Emergency Medical Services, as Needed
References
11. Foreign Body Ingestion and Aspiration
Incidence
Prevention
Rubber Dam
Oral Packing
Chair Position
Dental Assistant and Suction
Magill Intubation Forceps
Tongue-Grasping Forceps
Ligature
Management
Management of Ingested Foreign Bodies
Tracheobronchial Foreign Bodies
Recognition of an Airway Obstruction
Complete Airway Obstruction
Phase One
Phase Two – Minutes 2 Through 5
Phase Three
Partial Airway Obstruction
Basic Airway Maneuvers
Step 1: P (Position)
Step 2: C (Circulation)
Step 3: Head Tilt–Chin Lift
Step 4: A + B (Airway, Breathing)
Step 4a: Jaw-Thrust Maneuver, if Indicated
Step 5: A + B
Step 6: Rescue Breathing, if Indicated
Establishing an Emergency Airway in the Presence of an FBAO
Noninvasive Procedures
Back Blows
Abdominal Thrusts and Chest Thrusts
Abdominal Thrust (Heimlich Maneuver)
Chest Thrust
Finger Sweep
Procedures for An Obstructed Airway in An Infant
Invasive Procedures: Tracheostomy Versus Cricothyrotomy
Anatomy
Equipment
Step 1: Preparation of The Neck
Step 2: Identification of Landmarks
Step 3: Immobilization of The Larynx
Step 4: Incision of The Skin
Step 5: Reidentification of The Membrane
Step 6: Incision of The Membrane
Step 7: Dilation of The Incision
Step 8: Insertion of The Tube
Use of a 13-Gauge Needle for a Cricothyrotomy
Contraindications to Cricothyrotomy
References
12. Hyperventilation
Predisposing Factors
Prevention
Medical History Questionnaire
Physical Evaluation
Vital Signs
Dental Therapy Considerations
Clinical Manifestations
Signs and Symptoms
Effects on the Vital Signs
Pathophysiology
Management
Step 1: Terminate The Dental Procedure
Step 2: P (Position)
Step 3: C→A→B (Circulation-Airway-Breathing) Basic Life Support as Needed
Step 4: D (Definitive Care)
Step 4a: Removal of Materials From the Mouth
Step 4b: Calming of The Patient
Step 4c: Correction of The Respiratory Alkalosis
Step 4d: Drug Management, if Necessary
Step 5: Subsequent Dental Treatment
Step 6: Discharge
References
13. Asthma
Predisposing Factors
Extrinsic Asthma
Intrinsic Asthma
Mixed Asthma
Status Asthmaticus
Prevention
Medical History Questionnaire
Dialogue History
Dental Therapy Considerations
Clinical Manifestations
Usual Clinical Progression
Status Asthmaticus
Pathophysiology
Neural Control of the Airways
Airway Inflammation
Immunologic Responses
Bronchospasm
Bronchial Wall Edema and Hypersecretion of Mucous Glands
Breathing
Management
Acute Asthmatic Episode (Bronchospasm)
Step 1: Termination of the Dental Procedure
Step 2: P (Position)
Step 3: Removal of Dental Materials
Step 4: Calming of the Patient
Step 5: C→A→B (Circulation-Airway-Breathing) Basic Life Support as Needed
Step 6: D (Definitive Care)
Step 6a: Administration of O2
Step 6b: Administration of a Bronchodilator
Step 7: Subsequent Dental Care
Step 8: Discharge
Severe Bronchospasm
Step 1:
Step 2:
Step 3:
Step 4:
Step 5: 
Step 6: D (Definitive Care)
Step 6a: 
Step 6b: 
Step 6c: Call for Assistance
Step 6d: Administration of Parenteral Bronchodilators
Step 6e: Administration of IV Medications (Optional)
Step 6f: Additional Considerations
Step 7: Disposition of the Patient
References
14. Heart Failure and Acute Pulmonary Edema
The Impact of Demographics and Socioeconomic Status
Age
Sex
Race
Socioeconomic Status
Lifetime Risk of Heart Failure
Prognosis
Predisposing Factors
Prevention
Medical History Questionnaire
Section II, Have You Experienced
Section III, Do You Have, or Have You Had
Section IV, Do You Have, or Have You Had
Section V, Are You Taking
Dialogue History
Physical Evaluation
Vital signs
Physical Examination
Dental Therapy Considerations
Clinical Manifestations
Left Ventricular Failure
Right Ventricular Failure
Acute Pulmonary Edema
Pathophysiology
Normal Left Ventricular Function
Heart Failure
Management
Step 1: Termination of the Dental Procedure
Step 2: P (Position)
Step 3: Removal of Dental Materials
Step 4: Activate Office Emergency Team and Summons Emergency Medical Services
Step 5: Calming of the Patient
Step 6: C → A → B (Circulation-Airway-Breathing), Basic Life Support as Needed
Step 7: D (Definitive Care)
Step 7a: Administration of O2
Step 7b: Monitoring of Vital Signs
Step 7c: Alleviation of Symptoms
Step 7d: Bloodless Phlebotomy
Step 7e: Administration of a Vasodilator
Step 7f: Alleviate Apprehension
Step 8: Discharge
Step 9: Subsequent Dental Treatment
References
15. Respiratory Distress: Differential Diagnosis
Medical History
Age
Sex
Related Circumstances
Clinical Symptoms Between Acute Episodes
Position
Accompanying Sounds
Symptoms Associated With Respiratory Distress
Peripheral Edema and Cyanosis
Paresthesias of the Extremities
Use of Accessory Respiratory Muscles
Chest Pain
Heart Rate and Blood Pressure
Duration of Respiratory Distress
Part Four: Altered Consciousness
16. Altered Consciousness: General Considerations
Predisposing Factors
Prevention
Clinical Manifestations
Pathophysiology
Management
Step 1: Recognition of Altered Consciousness
Step 3: P (Position)
Step 4: C → A → B (Circulation-Airway-Breathing) Basic Life Support as Needed
Step 5: D (Definitive Care)
Step 5a: Monitoring of Vital Signs
Step 5b: Management of Signs and Symptoms
Step 5c: Activation of Emergency Medical Service, If Indicated
Step 5d: Definitive Management
References
17. Diabetes Mellitus
Overview
Chronic Complications
Acute Complications
Predisposing Factors
Type 1 Diabetes
Type 2 Diabetes
Types of Diabetes
Type 1 Diabetes
Type 2 Diabetes
Gestational Diabetes Mellitus
Prediabetes
Metabolic Syndrome
Hyperglycemia
Hypoglycemia
Control of Diabetes
Management of Type 1 Diabetes – Monitoring
Self-Monitoring of Blood Glucose Targets67
Measurement of Chronic Glycemic Control – Hemoglobin A1C
Management of Type 1 Diabetes – Treatment
Injectable Insulin
Management of Type 2 Diabetes
Prevention
Medical history questionnaire
Section II, Have You Experienced:
Section III, Do You Have, or Have You Had:
Section V, Are You Taking:
Dialogue History
Hemoglobin A1c Values:
Physical Examination
Dental Therapy Considerations
Clinical Manifestations
Hyperglycemia
Hypoglycemia
Pathophysiology
Insulin and Blood (Serum) Glucose
Hyperglycemia, Ketosis, and Acidosis
Hypoglycemia
Management
Hyperglycemia
Hyperglycemia—Conscious Patient
Hyperglycemia—Unconscious Patient
Step 1:
Step 2: P (Position)
Step 3:
Step 4: C → A → B (Basic Life Support), as Needed
Step 5: D (Definitive Care)
Step 5a: Summoning of Medical Assistance.
Step 5b: IV Infusion (if available).
Step 5c: Administration of Oxygen.
Step 5d: Transport of the Patient to the Hospital.
Hypoglycemia
Hypoglycemia—Conscious and Responsive Patient
Step 1: Recognition of Hypoglycemia
Step 2:
Step 3: P (Position)
Step 4: C → A → B (BLS, as Indicated)
Step 5: D (Definitive Care)
Step 5a: Administration of Oral Carbohydrates.
Step 6: Recovery
Hypoglycemia—Unresponsive Conscious Patient
Step 1:
Step 2:
Step 3:
Step 4:
Step 5: D (Definitive Care)
Step 5a: Administration of Oral Carbohydrates.
Step 5b: Summoning of Medical Assistance
Step 5c: Administration of Parenteral Carbohydrates – if Available
Step 5d: Monitoring of the Patient
Step 6: Discharge and Subsequent Dental Treatment
Hypoglycemia—Unconscious Patient
Step 1:
Step 2: P (Position)
Step 3: C → A → B (BLS, as Needed)
Step 4: D (Definitive Care)
Step 4a: Summoning of Medical Assistance.
Step 4b: Administration of Carbohydrates – if Available.
Step 5: Recovery and Discharge
References
18. Thyroid Gland Dysfunction
Predisposing Factors
Hypothyroidism
Hyperthyroidism/Thyrotoxicosis
Prevention
Medical history questionnaire
Section III, Do You Have, or Have You Had:
Section II, Have You Experienced:
Section IV, Have You Experienced:
Section V, Are You Taking:
Dialogue History
Physical Examination
Dental Therapy Considerations
Euthyroid
Hypothyroid
Hyperthyroid
Clinical Manifestations
Hypothyroidism
Thyrotoxicosis
Pathophysiology
Hypothyroidism
Hyperthyroidism and Thyrotoxicosis
Management
Hypothyroidism
Unconscious Patient with History of Hypothyroidism
Step 2: P (Position)
Step 3: C → A → B (Circulation-Airway-Breathing), Basic Life Support (BLS), as Needed
Step 4: D (Definitive Care)
Step 4a: Summoning of Medical Assistance
Step 4b: Establishment of an IV Line (If Available)
Step 4c: Administration of O2
Step 4d: Definitive Management
Thyrotoxicosis
Unconscious Patient With History of Thyrotoxicosis
Step 2: P (Position)
Step 3: C → A → B (BLS As Needed)
Step 4: D (Definitive Care)
Step 4a: Summoning of Medical Assistance
Step 4b: Establishment of an IV Line (If Available)
Step 4c: Administration of O2
Step 4d: Definitive Management
References
19. Cerebrovascular Accident
Classification
Transient Ischemic Attack (TIA)
Cerebral Infarction
Lacunar Infarcts
Cerebral Infarction
Hemorrhagic Stroke: Intracerebral Hemorrhage and Subarachnoid Hemorrhage
Predisposing Factors
Hypertension
Diabetes Mellitus
Disorders of Heart Rhythm
Smoking and Tobacco Use
Physical Inactivity
Nutrition
Family History and Genetics
Kidney Disease
Risk Factors Specific to Females
Sleep-disordered Breathing and Sleep Duration
Prevention
Medical History Questionnaire
Section I, Circle Appropriate Answer:
Section II, Have You Experienced:
Section III, Do You Have or Have You Had:
Section IV, Do You Have or Have You Had:
Section V, Are You Taking:
Dialogue History
Physical Examination
Vital Signs
Apprehension
Dental Therapy Considerations
Length of Time Elapsed Since the Stroke
Minimization of Stress
• Absolute avoidance of an epinephrine-impregnated
gingival retraction cord
Assessment of When a Poststroke Patient Represents Too Great a Risk for Treatment
Assessment of the Risk of Bleeding
Clinical Manifestations
Transient Ischemic Attack
Cerebral Infarction
Cerebral Embolism
Cerebral Hemorrhage
Pathophysiology
Cerebrovascular Ischemia and Infarction
Hemorrhagic CVA
Management
Cerebrovascular Accident and Transient Ischemic Attack
Step 1: Discontinuation of the Dental Procedure
Step 1a: Activation of Dental Office Emergency Team
Step 2: P (Position)
Step 3: C→A→B (Circulation-airway-breathing), BLS as Needed
Step 4: D (Definitive Care)
Step 4a: Activation of EMS
Step 4b: Monitoring of Vital Signs
Step 4c: Management of Signs and Symptoms
Step 4d: Administration of O2
Conscious Patient with Resolution of Signs and Symptoms: Transient Ischemic Attack
Conscious Patient with Persistent Signs and Symptoms: Cerebrovascular Accident
Step 1: P (Position)
Step 2: C→A→B, BLS as Needed
Step 3: Monitoring of Vital Signs
Step 4: Repositioning of the Patient (if Necessary)
Step 5: D (Definitive Care)
Step 5a: Establishment of IV Access, If Available
Step 5b: Definitive Management
References
20. Altered Consciousness: Differential Diagnosis
Medical History
Age
Sex
Related Circumstances
Onset of Signs and Symptoms
Presence of Symptoms Between Acute Episodes
Loss of Consciousness
Signs and Symptoms
Appearance of the Skin (Face)
Obvious Anxiety
Paresthesia
Headache
“Drunken” Appearance
Breath Odor
Vital Signs
Respiration
Blood Pressure
Heart Rate
Summary
Part Five: Seizures
21. Seizures
 Types of Seizure Disorders
Focal-onset Seizures
Generalized Seizures
Generalized Tonic-clonic Seizures (Grand Mal Epilepsy)
Absence Seizures
Jacksonian Seizures
Psychomotor Seizures
Status Epilepticus
 Causes
Predisposing Factors
Prevention
Nonepileptic Causes
Epileptic Causes
Medical History Questionnaire
Section I, Circle Appropriate Answer
Section II, Have You Experienced
Section V: Are You Taking
Dialogue History
Physical Examination
Psychological Implications of Epilepsy
Dental Therapy Considerations
Minimal or Moderate Sedation
Clinical Manifestations
Partial Seizures
Absence Seizures (Petit Mal)
Generalized Tonic-clonic Seizure
Prodromal Phase
Preictal Phase
Ictal Phase
Tonic Component
Clonic Component
Postictal Phase
Tonic-clonic Seizure Status (Grand Mal Status, Convulsive Status Epilepticus)
Pathophysiology
Management
Absence Seizures and Partial Seizures
Step 1: Recognition of the Problem
Step 2: Termination of the Dental Procedure
Step 3: Activation of the Office Emergency Team
Step 4: P (Position)
Step 5: Reassurance of the Patient
Step 6: Discharge of the Patient and Subsequent Dental Care
Generalized Tonic-clonic Seizures
Prodromal (preictal)
Step 1: Recognition of the Problem (Aura) and Termination of the Dental Procedure
Ictal Phase
Step 2: Activation of the Dental Office Emergency Team
Step 3: P (Position)
Step 4: Consideration of Summoning Emergency Medical Services (EMS)
Step 5: C → A → B (Circulation-Airway-Breathing)—Basic Life Support, as Needed
Step 6: D (Definitive Care)
Step 6A: Prevention of Injury
Postictal phase
Step 7: P (Position)
Step 8: C → A → B—Basic Life Support, as Needed
Step 9: Monitoring of Vital Signs
Step 10: Reassurance of the Patient and Recovery
Step 11: Discharge
Grand Mal Status
Preictal Phase
Step 1: Recognition of the Problem (Aura) and Termination of the Dental Procedure
Ictal Phase
Step 2: Activation of the Dental Office Emergency Team
Step 3: P. Position the Convulsing Patient Supine with their Feet Elevated Slightly
Step 4: Summoning of Medical Assistance
Step 5: C → A → B—Basic Life Support, as Needed
Step 6: D (Definitive Care)
Step 6a: Protection of the Patient from Injury
Step 7: Venipuncture and Administration of the Anticonvulsant Drug
Step 8: Administration of a 50% Dextrose Solution
Step 9: Subsequent Management
 Differential Diagnosis
References
Part Six: Drug-Related Emergencies
22. Drug-Related Emergencies: General Considerations
Prevention
Medical History Questionnaire
Section I, Circle Appropriate Answer:
Section III, Do You Have or Have You Had:
Section V, Are You Taking:
Dialogue History
Care in Drug Administration
Classification
Overdose Reactions
Allergy
Idiosyncratic Drug Reactions
Management of Idiosyncratic Reactions
Drug-Related Emergencies
Drug Use in Dentistry
Local Anesthetics
Antibiotics
Analgesics
Sedatives
Inhalation Sedation
References
23. Drug Overdose Reactions
 LAST – Local Anesthetic Systemic Toxicity
Predisposing Factors
Patient Factors
Normal Distribution Curve
Age
Body Weight and Maximum Recommended Doses (MRDs)
Pathologic Process
Genetics
Attitude and Environment
Sex
Drug Factors
Vasoactivity
Dose
Route of Administration
Rate of Injection
Vascularity of the Injection (Deposition) Site
Presence of Vasoconstrictors
Prevention
Medical History Questionnaire and Dialogue History
Etiology of LAST Reactions
Biotransformation and Elimination
Too Large a Total Dose
Rapid Absorption of the Drug into the Circulation
Intravascular Injection
Administration Technique
Clinical Manifestations
Onset, Intensity, and Duration
Signs and Symptoms
Minimal to Moderate Blood Levels
Moderate to High Blood Levels
Pathophysiology
Local Anesthetic Blood Levels
Systemic Activity of Local Anesthetics
Cardiovascular Actions
CNS Actions
Management
Mild Overdose Reaction with Rapid Onset
Step 1:
Step 2: P (Position)
Step 3:
Step 4: C→ A → B (Circulation-Airway-Breathing), Basic Life Support (BLS) as Needed
Step 5:
Step 5a: Administration of O2
Step 5b: Monitoring of Vital Signs
Step 5c: Administration of an Anticonvulsant Drug, If Needed
Step 5d: Summoning of Emergency Medical Assistance
Step 6: Recovery and Discharge
Mild Overdose Reaction with a Delayed Onset (>10 Min)
Step 1:
Step 2: P (Position)
Step 3:
Step 4: C → A → B (Circulation, Airway, Breathing, Circulation) or BLS, As Needed
Step 5:
Step 5a:
Step 5b:
Step 5c: Administration of Anticonvulsant, If Needed
Step 5d: Summoning of Medical Assistance (Optional)
Step 5e: Medical Consultation
Step 6: Recovery and Discharge
Step 7: Subsequent Dental Treatment
Severe Overdose Reaction with a Rapid Onset
Step 1: P (Position)
Step 2: Summoning of Emergency Medical Assistance
Step 3: C → A → B
Step 4:
Step 4a: Administration of O2
Step 4b: Protection of the Patient
Step 4c: Monitoring of Vital Signs
Step 4d: Venipuncture and IV Anticonvulsant Administration
Step 4e: IV Lipid Resuscitation
Step 5: Postictal Management
Step 5a:
Step 5b: Monitoring of Vital Signs
Step 5c: Additional Management Considerations
Step 6: Recovery and Discharge
Severe Overdose Reaction with Slow Onset
Step 1: Terminate the Dental Treatment
Step 2: P (Position)
Step 3:
Step 4:
Step 4a:
Step 4b:
Step 4c:
Step 4d:
Step 4e: Venipuncture and Administration of IV Anticonvulsant
Step 5: 
Step 5a:
Step 5b: Monitoring of Vital Signs
Step 5c: Additional Management Considerations
Step 6: Recovery and Discharge
Epinephrine (Vasoconstrictor) Overdose Reaction
Precipitating Factors and Prevention
Clinical Manifestations and Pathophysiology
Management
Step 1: Terminate the Procedure
Step 2: P (Position)
Step 3: C → A → B (Circulation, Airway, Breathing) or BLS, As Needed
Step 4: D (Definitive Care)
Step 4a: Reassurance of the Patient
Step 4b: Monitoring of Vital Signs
Step 4c: Summoning of Medical Assistance
Step 4d: Administration of O2
Step 4e: Recovery
Step 4f: Administration of a Vasodilator (Optional)
Step 5: Discharge
Central Nervous System Depressant Overdose Reactions
Predisposing Factors and Prevention
Individual Variation—The Normal Distribution Curve
Clinical Manifestations
Sedative-hypnotics
Sedation and Oversedation
Hypnosis
General Anesthesia
Respiratory Arrest
Opioid Agonists
Management
Sedative-Hypnotic Drugs
The Concept of “Rescue”
Step 1: Terminate the Dental Procedure
Step 2: P (Position)
Step 3: C → A → B (Circulation, Airway, Breathing) BLS, As Needed
Step 4: D (Definitive Care)
Step 4a: Summoning of Medical Assistance, If Needed
Step 4b: Administration of O2
Step 4c: Monitoring of Vital Signs
Step 4d: Establishment of an IV Line, If Possible
Step 4e: Definitive Management
Step 5: Recovery and Discharge
Opioid Analgesics
Step 1:
Step 2: P (Position)
Step 3: C → A → B (Circulation, Airway, Breathing) or BLS, As Needed
Step 4: D (Definitive Care)
Step 4a: Summoning of Medical Assistance, If Needed
Step 4b: Administration of O2
Step 4c: Monitoring and Recording of Vital Signs
Step 4d: Establishment of an IV Line, If Possible
Step 4e: Antidotal Drug Administration
Step 5: Recover
Step 6: Discharge
 Summary
References
24. Allergy
Predisposing Factors
Antibiotics
Analgesics
Antianxiety Drugs
Local Anesthetics
Other Agents
Prevention
MEDICAL HISTORY QUESTIONNAIRE
Section II, Have You Experienced
Section III, Do You Have or Have You Had
Dialogue History
Medical Consultation
Allergy Testing in the Dental Office
Dental Therapy Modifications
Allergies to Drugs Other Than Local Anesthetics
Management
Alleged Allergy to Local Anesthetics
Elective Dental Care
Emergency Dental Care
Option 1: Consultation
Option 2: General Anesthesia
Option 3: Injectable Histamine Blocker
Confirmed Allergy to Local Anesthetics
Clinical Manifestations
Onset
Skin Reaction
Respiratory Reactions
Generalized Anaphylaxis
Pathophysiology
Antigens, Haptens, and Allergens
Antibodies (Immunoglobulins)
Defense Mechanisms of The Body
Type I Allergic Reaction—Anaphylaxis
Sensitizing Dose
Challenge (Allergic) Dose
Chemical Mediators of Anaphylaxis
Histamine
Leukotrienes – Slow-Reacting Substance of Anaphylaxis
Eosinophilic Chemotactic Factor of Anaphylaxis
Respiratory Signs and Symptoms
Cardiovascular Signs and Symptoms
Gastrointestinal Signs and Symptoms
Urticaria, Rhinitis, and Conjunctivitis
Management
Cutaneous Reactions
Management – Delayed-onset Cutaneous Reaction
Step 1: Terminate the Dental Procedure and Activate the Dental Office Emergency Team
Step 2: P (Position)
Step 3: C → A → B (Circulation-Airway-Breathing). Basic Life Support (BLS), As Needed
Step 4: Monitor and Record Vital Signs
Step 5: D (Definitive Care)
Step 5a: Administration of a Histamine Blocker
Step 6: Recovery and Discharge
Step 7: Medical Consultation
Management – Rapid-onset Cutaneous Reaction
Step 1: Terminate the Dental Procedure and Activate the Dental Office Emergency Team
Step 2: P (Position)
Step 3: C → A → B (Circulation, Airway, Breathing). Basic Life Support (BLS), As Needed
Step 4: Monitor and Record the Vital Signs
Step 5: D (Definitive Care)
Step 5a: Oxygen and, If Available, Venipuncture
Step 5b-1:
Step 5b-2: Activate Emergency Medical Services
Step 5c: Reposition the Patient if there is a Change in Status
Step 5c-1: Consider a Bronchodilator for Wheezing
Step 5d: Administration of a Parenteral Histamine Blocker
Step 5e: Recovery and Discharge
Management – 
Bronchospasm
Step 1:
Step 2: P (Position)
Step 3: C → A → B (Circulation, Airway, Breathing). Basic Life Support (BLS), As Needed
Step 4:
Step 5: Calming of the Patient
Step 6: Monitor and Record Vital Signs
Step 7: D (Definitive Care)
Step 7a: Summoning of Medical Assistance
Step 7b-1:
Step 7b-2: Consider the Administration of Epinephrine
Step 7c: Monitoring of the Patient
Step 7d: Recovery and Discharge
Management – Laryngeal Edema
Step 1:
Step 2: P (Position)
Step 3: C → A → B (Circulation, Airway, Breathing). Basic Life Support, As Needed
Step 4: D (Definitive Care)
Step 4a:
Step 4b: Administration of Epinephrine
Step 4c: Airway Management
Step 4d: Administration of Oxygen
Step 4e: Consider Additional Drug Management
Step 4f: Cricothyrotomy
Epinephrine and Anaphylaxis
Management – Generalized Anaphylaxis
Signs of Allergy Present
Step 1:
Step 2: P (Position)
Step 3: C → A → B (Circulation, Airway, Breathing). Basic Life Support (BLS), As Needed
Step 4: Monitor and Record Vital Signs
Step 5: D (Definitive Care)
Step 5a: Summoning of Medical Assistance
Step 5b: Administration of Epinephrine
Step 5c: Administration of Oxygen
Step 5d: Additional Drug Therapy
No Clinical Signs of Allergy Present
Step 1:
Step 2: P (Position)
Step 3: C → A → B. Basic Life Support, As Needed
Step 4: Monitor and Record Vital Signs
Step 5: D (Definitive Care)
Step 5a: Summoning of Emergency Medical Assistance
Step 5b:
Step 5c: Definitive Management
References
25. Drug-Related Emergencies:  Differential Diagnosis
Differential Diagnosis
Medical History
Age
Sex
Position
Onset of Signs and Symptoms
Prior Exposure to Drug
Dose of Drug Administered
Overall Incidence of Occurrence
Signs and Symptoms
Duration of Reaction
Change in the Appearance of the Skin
Appearance of Nervousness
Loss of Consciousness
Presence of Seizures
Respiratory Symptoms
Vital Signs
Heart Rate
Blood Pressure
Summary
References
Part Seven: Chest Pain
26. Chest Pain
General Considerations
Predisposing Factors
Risk Factors for Atherosclerotic Cardiovascular Disease
Age
Sex
Race and Ethnicity
High Blood Cholesterol and Other Lipids
High Blood Pressure
Smoking and Tobacco Use
Physical Inactivity
Overweight and Obesity
Family History and Genetics
Diabetes Mellitus
Metabolic Syndrome
Chronic Kidney Disease
Mental Stress and Cardiovascular Risk
Prevention
Clinical Manifestations
Pathophysiology
Atherosclerosis
Location
Chest Pain
Management
References
27. Stable Ischemic Heart Disease – Angina Pectoris
Predisposing Factors
Prevention
MEDICAL HISTORY
Section II, Have You Experienced:
Section III, Do You Have or Have You Had:
Section IV, Do You Have or Have You Had:
Section V, Are You Taking:
Control of Acute Anginal Symptoms
Dialogue History
Physical Examination
Unstable Angina
Dental Therapy Considerations
Length of The Appointment
Supplemental Oxygen
Pain Control During Therapy
Sedation
Additional Considerations
Vital Signs
Nitroglycerin Premedication
Clinical Manifestations
Signs and Symptoms
Pain
Radiation of Pain
Physical Examination
Complications
Prognosis
Pathophysiology
Management
Patient With a History of AP
Step 1: Termination of the Dental Procedure and Activation of the Office Emergency Team
Step 2: P (Position)
Step 3: C→A→B (Circulation-Airway-Breathing), Basic Life Support (BLS), As Needed
Step 4:
Step 5: D (Definitive Care)
Step 5a: Administration of Vasodilator and Oxygen
Effects and Side Effects of Nitroglycerin
Action of Nitroglycerin
Step 5b: Administration of Additional Doses of Vasodilator, If Necessary
Step 5c: Summoning of Medical Assistance, If Necessary
Effects and Side Effects of Calcium Slow-channel Blockers
Step 6: Modification of Future Dental Therapy
No History of Chest Pain
References
28. Acute Coronary Syndrome – Myocardial Infarction
 Predisposing Factors
The Blood Supply to The Heart — Coronary Artery Anatomy
Location and Extent of Infarction
Collateral Circulation
 Prevention
 MEDICAL HISTORY
Section II, Have You Experienced
Section III, Do You Have or Have You Had
Section IV, Do You Have or Have You Had
Section V, Are You Taking
Dialogue History
Physical Examination
 Dental Therapy Considerations
Stress Reduction
Supplemental Oxygen
Sedation
Pain Control
Duration of Treatment
Elapsed Time Since Mi
Medical Consultation
Anticoagulant or Antiplatelet Therapy
 Clinical Manifestations
Pain
Other Clinical Signs and Symptoms
Physical Findings
Acute Complications
 Pathophysiology
 Management
Step 1: Terminate the Dental Procedure; Activate Office Emergency Team
Step 2: Diagnosis
Step 3: P (Position)
Step 4: C → A → B (Circulation-Airway-Breathing). Basic Life Support, As Needed
Step 5: Monitor and Record Vital Signs
Step 6: D (Definitive Care)
Step 6a: Summoning of Medical Assistance
Step 6b: Administration of Oxygen — Yes or No?
Step 6c: Administration of Nitroglycerin
Step 6d: Antiplatelet Therapy
Step 6e: Relief of Pain
Step 7: Preparation to Manage Acute Complications
Step 8: Transportation of Patient to Hospital
Immediate In-Hospital Management
Fibrinolytic Therapy
Percutaneous Coronary Intervention
References
29. Chest Pain: Differential Diagnosis
Noncardiac Chest Pain
Cardiac Causes of Chest Pain
Medical History
Age
Sex
Related Circumstances
Clinical Symptoms and Signs
Location of Chest Pain
Description of Chest Pain
Radiation of Chest Pain
Duration of Chest Pain
Response to Nitroglycerin
Vital Signs
Heart Rate
Blood Pressure
Respiration
Other Signs and Symptoms
Summary
References
Part Eight: Cardiac Arrest
30. Cardiac Arrest
Survival from Sudden Cardiac Arrest
Witnessed Versus Unwitnessed
Initial Rhythm Encountered
Bystander CPR
Response Time
The Chain of Survival
The First Link: Activation Of Emergency Response
The Second Link: High-Quality CPR
The Third Link: Rapid Defibrillation
The Fourth Link: Effective Advanced Resuscitation
The Fifth Link: Post–Cardiac Arrest Care
The Sixth Link: Recovery
The Dental Office
Sudden Cardiac Arrest
Pulmonary (Respiratory) Arrest
Cardiac Arrest
Basic Life Support (CPR)
Team Approach
Basic Life Support
Cardiac Arrest In The Dental Office
Cpr Sequence—Adult Victim
Step 1: RECOGNITION of Unconsciousness
Step 2: Summon Assistance and P—Position the Victim
Step 3: C—Assessment of Circulation and Chest Compressions, If Needed
Step 4: A—Assessment and Maintenance of Airway
Step 5: B—Breathing
Step 5a: B—Assessment of Breathing and Ventilation, If Needed
Step 5b: Rescue Breathing
Step 6: Defibrillation
CPR Specifics—Activating EMS
CPR Specifics—Circulation
Assessment of Circulation
Chest Compressions
CHEST COMPRESSION
Location of the Compression Point
Application of Pressure
Rate of Chest Compression
Compression–Ventilation Ratio
CHEST COMPRESSIONS
Cpr Specifics—Defibrillation
DEFIBRILLATION
Beginning and Terminating Bls
Transport of Victim
References
31. Pediatric Considerations
Preparation
Basic Life Support
Pediatric Advanced Life Support
Emergency Team
Access To Emergency Medical Services
Emergency Drugs and Equipment
Basic Management
Position
Circulation
Airway and Breathing
Definitive Care
Specific Emergencies
Bronchospasm (Acute Asthmatic Attack)
Recognition
P, C, A, B
D (Definitive Care)
Generalized Tonic-Clonic Seizure (Grand Mal Seizure)
Recognition
P, C, A, B
D (Definitive Care)
Postseizure Management
D (Definitive Care)
REMEMBER
REMEMBER
CNS-depressant (Sedation) Overdose
Recognition
P, C, A, B
D (Definitive Care)
For Children Between 5 and 17 Years of Age
For Children Younger than 5 Years or Weighing 20 kg or Less
REMEMBER
Local Anesthetic Systemic Toxicity (Last) (Local Anesthetic Overdose)
Recognition
P, C, A, B
D (Definitive Care)
Respiratory Arrest
Recognition of Respiratory Distress
Management of Airway Obstruction
Recognition of Respiratory Arrest
Use of the Face Mask
REMEMBER
REMEMBER
Cardiac Arrest
Differences Between Adult and Pediatric Cardiac Arrest
Adults
Children
CPR Sequence—Child Victim (Age 1 Year to the Onset of Puberty)
RESCUE BREATHING FOR THE CHILD VICTIM
PULSE CHECK
CHARACTERISTICS OF GOOD CHEST COMPRESSIONS—CHILD
Step 1: Recognition of Unconsciousness
Step 2: Summoning of Assistance and P (Position the Patient)
Step 3: C (Circulation)
Step 3a: Assessment of Circulation
Step 3b: Chest Compressions
Step 4: A (Assess and Maintain the Airway)
Step 5: B (Breathing)
Step 5a: Assess Breathing and Ventilate, If Needed
Step 5b: Rescue Breathing
Step 6: Activate EMS
Step 7: Defibrillation
AED Technique (Child)
References
Appendix: Quick-Reference Section to Life-Threatening Situations