practitioner would practice as "a resonsably prudent" practioner would do under the same or simualr circumstances.
ex: patient comes in expectation use sterilse instrument. If dropped and still used that woule be under standard of care.
laws (differ from state to state) that do not hold the health care provider liable for death or injury (except in cases of gross neglect) in cases where they render emergency life and death treatment in good faith to individuals who are not their pateints (individuals for whose treatment they do not expect to be compensated)
ex: cant get suide for trying to save someones life if done what should have been done. (if not a patient of yours)
Duty to act
the dentist has an OBLIGATION to treat the in his office if the emergency victim is indeed the dentist patient.
-Failure to treat a patient in a medical emergency or failing to carry out treatment.
-leaving patient once tx is started
-failing to tx patient
-failing to complete patients tx
Consent/ Informed Consent (8)
-requires that the patient be made aware(usualy by the dentist) in sufficient details so the patient understands:
-reasons for care and tx
-nature of care/ tx
-risks involved (known risks)
-expectations of sucess
-possible results if patient refuses to undergo care of tx/ does not follow instructions
-failure to practice ordinary or do something the ordinary prudent practioner would not do under same/ simular circumstances or not doing something they would do.
-if you have acted megligently you have performed malpractice.
-negligence and malpractice are interchangable
-physical examination of patient (extra/intra oral)
-use above to determine physical and psychological status of patients
-seek medical consultation
-institute appropriate tx modifcations
-increased anxiety and fear of dentistry can lead to EXACERBATION(worsening) of medical problems (I.E asthma, seizures, angina,etc)
-Obsercation- as a follow up to questions assesing anxiety the following may be seen:
-increased blood pressure and heart rate
Patients Anxiety Level
Recognizing anxious patients
- start worrying about appt up to 1-2 days before appt.
-visual observation: wringing of hands, sweaty palms, death grip
-Verbal- id rather have a baby then come to the dentist, rapid, run on speech, slow, rambling speech
Stress Reduction Protocols(3)
-Premedications-(prescribed by dentist or physican)-helpful for some anxious patients:
-night before appt: valium, xanax
-one hour before tx: Diazepam (patient should not drive car)
Scheduling Stree Protocol (3)
-recognize that patient is anxious and mecidally compromised, obtain medical consultation prior to scheduling tx.
-schedule appt for early in day
-consider use of premeds
On the Day of Appt.(4)
-Do not keep patient waiting in reception area of dental chair.
-obtain vitals before tx. Monitor vitals during and after tx.
-maintain adequate pain control during tx: topical anesthetics, local anesthetic, sedation.
-stage 1 hypertension: blood pressure between 140-159 systolic and or 90-99 diastolic
ASA III (Tx Modifications) (3)
1.consultation with physician as needed
2. stress reduction protocol
3. routine elective tx can USUALLY be given
ASA IV, V, VI
ASA IV- patients with severe systemic disease that limits activity and is constant threat to life. Elective tx should be postponed until patient condition improves so ASA III
ASA V- Moribund patients not expected to survive 24 hours with or without an operation
ASA VI- clinically dead patients being maintained for harvesting or organs
ASA Physical status Classification System
ASA I- patients are considered to be normal and healthy. Patients are able to walk up one flight of stairs or two level city block without distress. Little or no anxiety. Little or no risk. This classification represents a "green flag" for tx.
ASA II (Colors)
Patients have mild to moderate systemic disease or are healthy ASA I patients who demonstrate a more extreme anxiety and fear toward dentistry. Patients are able to walk up one flight of stairs or two level city blocks, but will have to stop after completion of the excercise because of distress. Minimal risk during tx This classification represents a Yellow Flag for tx.
ASA II Colors Examples
Examples: History of well controlled diease states including noninsulin dependent diabtetes, prehypertention, epilepsy, asthma, smoker, throid conditions, ASA I wih a respiratory condition, pregnancy and or active allergies may need medical consultation
NOTE: patients who demonstate a more exteme anxiety of fear toward dentistry have a baseline of ASA II even before their medical history is considered. that situation raises the classication system.
ASA III Colors
patients have severe systemic disease that limits activity, but is not incapacitating. Patients are able to walk up one flight of stairs r two level city blocks. but will have to stop enroute because of distress. If dental care is indicated, stree reduction protocol and other tx mods are indicated. This classicication represents a Yellow Flag for tx.
ASA III Examples
Examples: History of Angina pectoris, myocardial infarcation, cerebrovascular accident, congestice heart failure over six months ago, slight chronic obstructive pulmonary disease, controlled insulin dependent diabetes or hypertension.
Will need medical consultation
ASA IV Colors
-Patients have severe systemic disease that limits activity and is a constand threat to life. Patients are unable to walk up one flight of stairs or two level city blocks. Distress is present even at rest. Patients pose significant risk since patients in this category have a severe medical problem of greater importantce to the patient than the planned dental tx. -Elective dental care should be postponed until such time as the patients medical condition has improved to atleast an ASA III class.
ASA IV Examples
-Represents a red flag a warning flag indication that the risk onvolved in tx is too great allow elctive care to prodceed.
Examples: history of unstable angina pectoris, myocardial infarction or cerebrovascular accident within the last 6 months, severe congestive heart failure, moderate to severe chronic obstructive pulmonary disease, uncontrolled diabetes, hypertension, eplilepsy, throid condition.
If emergency tx is needed medical consult is indic.
ASA V Colors
Patients are moribund and are not expected to survive more than 24 hours with or without an operation. These patients are almost always hospitalized, terminally ill patients. Elective dentl tx is defintly contraindicated. A red Flag for dental care.
emergency operation of any variety used to modify one of the above classicifications (ASA III-E)
Implication for Dental tx Relaing to Health Status Levels (4)
Level1- patient can recieve routine dental tx.
LevelII-routine dental tx may require tx modificaion such as: medical consultation, shortned appt., use of sedative or antibiotic premed.
LevelIII-Routine dental tx is indicated, but will require tx modd
LevelIV- only emergency dental tx is indicated. postponed until imporved to level III
PP2. Asses Patient for Routine Treatment (6)
-first interaction (voice) shakie, grasp
-Gait (way walk)
-apperance(dirty, messy, pale)
-Document in patients chart
during medical emergency, vitals are taken and compared to baseline
in medical emergency if patient expericne fight or flight reaction = compensation= vitals have increased over baseline= elevated
vitals have fallen below baseline= patients could be going into shock
state of lack of perfusion (saturation) of oxygenated blood in all cells of body and brain.
Communication Posted near telephones(4)
Commerical Vs. Homemade Emergencu Drug Kits
-false sense of security with commerical kits
-best emergency kits are ones desiigned to meet specific needs and requirmentd of individual practice =simple not complicated.
Identify. Record Drugs
Clearly identified, keep in clear plastic containers.
Check experation dates, enter.
Record emergency paper.
Stop watch time happened
Copy for hospital
Practice and Drill
Staff instruction- everyone in office must be familar with location, purpose, effect and application of equipment.
Assignment- specific resosiblities should be assigned to prevent confusion
Flow chart- may want to post
Drills- should be conducted practiced once a month suprise if possible
New staff memebers
-the one in charge
-requests and administers drugs
Dental Assistant (clinic aid)(6)
-on signal- does to emregncy cart-starts stopwatch
-Brings cart and O2 to operatory
-Places cart so BP facing hygienest
-Airways oxygen delivery devices facing doctors
-Sets up 02 delivery devices per doc orders
-Turns refence table to prop page
-Moves cart to extreme rifht with CPR needed
-Helps move patient to the floor
Dental Hygienst (4)
-Make sure stopwatch has been started
-Takes vital Signs
-Records all info on emergency report and enters stopwatch times for each notation
-Assits as needed with emergency care.
-Evacuates other patients
-Assists as needed per Dr's request
Paitient Role Play
-Act the part of patient in emergency
-Displays or desribes manifestations including signs and sympyoms
Oxygen- used for most all emergencies except hyerventilation
-counteracts major physiological events in anaphylasis.
-Reduces hypotension, bronchosparm, layngeal edema, prevents additional realse of hisamine. -----------for severe astham attack
-Should not use with ischemic heart diease or sever hypertension
Albuterol- asthma attacks or bronchospasm.
-Dilation of bronchioles with minimal cardiovascular effects.
-Short Onset 30-60 mins
-Long Onset 4-6 hours.
-Adult dose 2 sprays
-Pediatric 1 dose
-Can repeat doses if necessary
-reduces overall mortality from MI
-prevents progression of cardiac ischemia to cardiac injury or to cardiac tissue death
-recommended dose 162 mg-325 mg 2-4 baby asprin
-check medical hix for allgery
-not actually a drug but inclusion necessary
-paste or tablets do not require refrigeration
-increase heart rate which way also increase BP
-Recomemded dose .5mg
-BP cuff and stethoscope
-thermometer with sleevs
-pocket mask with one way valve
-band-aids and sterile gauze
Oxygen Deliver System Administration
-needed when breathing is inadequate for keeping the blood saturated with oxygen.
-colorless, odorless gas
-compressed gas tanks
-21% in air
-tanks of oxygen are GREEN
-sizes are letered by cylinder
Series of Cylinder
-Series E cylinder is portable carriage recommended for dental opertories
Safety precautions with O2
- no petrolium jelly, open flames or sparks, cigarettes pipe, avoid excessive heat
-dont stand over it when adjusting it
-connect and adjust system before administering O2 to patient.
-use caution with COPD patients and hyperventilation emergencies.
-use clear mask to see vomiting
Parts of O2 Tank
-Cylinder (holds O2)
-Flow Meter ( How much O2)
holds 30 mins of O2
Types of Delivery Devices in Dental Office
-non-rebreathing face mask
-rests on patients upper lip
-prolongs inserted into nasal passages
-looped around patients ears
-oxygen flow 1-6 liters/min
-turn on prior to placement
-low to moderate flow rate
Simple Face Mask
-Delivers slightly more O2 consentration
-Over the mouth and nose
-approp size for children
-8-12l/min 60% o2
-use when cannula is not tolerated
Non Rebreathing face Mask
-reservoir attached to provide extra oygen
-placed over patients nose and mouth
-straps tightened around patients head
-patient place mask to reduce apprehension
-one way valve to prevent exhaled gas from mixing wiht o2 in reservoir
-one way valve on exhalation port so room air does not enter mask
-for High flow
-patients in shock
-used for respiratory arrest when patients needs complete oxygen delivery
-difficult to obtain leak proof seal around face
-use 3rd 4th 5th finger on bony portion of mandible and thumb and index finger on mask to obtain good seal
-two rescuers recommended
-durinf ventilation should not see chest rise if not reposition head to open airway.
Bag Valve Mask
-for CPR in semi-conscious patients
-21% O2 without oxygen tank
-40-100% when connected to O2 tank
-depends on valve system
-flow rate of 15
The Demand Valve
-push button lever connected tp face mask
-when lever is released preset pressure is set
-oxygen automatically stops
-for use by EMS and ACLS personnel only
-Color coded knobs to regulate room air mixed with oxygen
PP3 Predisposing Factors
-impaired physical status
-Administraion or ingestion of drugs
-medical/ dental history
-use of stress reduction protocol
Mechanisms That Produce Unconsciousness
-reduced blood flow to the brain (most common)
-systemic or local metabolic deficiencies
-Alterations within the brain itself or on the central nervous system.
Recognition of Unconsciousness three criteria
- lack of response to sensory stimulation
-loss of protective reflexes
-inability to maintain a patient airway.
Unconscious states we will be covering:
-postural hypotension (orthostatic hypotension)
-acute adrenal insufficiency
AKA Vasovagal syncope
Defintion: A sudden temp loss of cousciousness, the result of temp decrease of blood flow to the brain.
-most common medical emerg in dental office.
Predisposing factors for Vasodepressors Syncope
Psychogenic Factors- fright anxiety emtional stress, pain, especially sudden unexpected, sight of clood instruments La syringe.
Non psychogenic Factors- standing/sitting upright
hunger from diet missing meal, exhaustion,
poor physical condition, hot humid crowded envirments, male.
Clinical Manifestations of Presyncope Early/Late
Early: feeling warm, loss of color pale,heavy perspirations, feeling faint,nausea, BP at baseline or slightly lower.