Management of acute asthamic attack.pptx

management of acute asthamatic attack

1. Management of Acute Asthmatic Episode and Epilepsy in the Dental. Office Presented by Ram Subramanian

2. ▶ INTRODUCTION ▶ PREVENTION ▶ RESPIRATORY DISTRES S - ▶ Asthma ▶ SEIZURES- ▶ EPILEPSY ▶ CONCLUSION

3. Introduction Goldberger 1990, “When you prepare for an emergency, the emergency ceases to exist.”

4. Prevention Goals of physical evaluation Physical evaluation – ▶ Medical history questionnaire, ▶ Physical examination ▶ Dialogue history.

5. ASA Physical Status Classification ▶ Class1: Healthy patient with no systemic disease. ▶ Class 2: Mild Systemic disease with no limits on activity. ▶ Class 3: Severe systemic disease that limits activity. ▶ Class 4: Incapacitating systemic disease that is life threatening. ▶ Class 5: Moribund and E refers to emergency of any kind.

6. Anxiety recognition & stress reduction protocol ▶ Recognize patient’s anxiety level. ▶ Consider using pre- medication or sedation ▶ Schedule morning appointments. ▶ Minimize waiting time and watch appointment length. ▶ Make sure to use adequate pain control. This will vary from patient to patient. ▶ Monitor vital signs. ▶ Medical consult if required . Stanley F Malamed – Med emergencies in the dental office : 8 th Ed

7. Emergency drug kits

8. Module one – critical or essential emergency drugs Category Generic drug alternative quantity Availability Allergy – anaphylaxis Epinephrine None 1 preloaded syringe +3x1 ml ampules 1:1000 (1mg/ml) allergy – histamine blocker Chlorphenira mine Diphenhydra mine (Benadryl) 3x1 ml ampules 10 mg/ml Oxygen Oxygen 1 “E” cylinder Vasodilator Nitroglycerin Nitrostat sublingual tablets 1 metered spray bottle 0.4 mg /metered dose Bronchodilator Albuterol Metaproterenol 1 metered dose inhaler Metered aerosol inhaler Antihypoglyce mic Sugar Insta – glucose gel 1 bottle Inhibitor of platelet aggregation Asprin None 2 packets 325mg/tablet Stanley F Malamed – Med emergencies in the dental office : 8 th Ed

9. Equipment Recommended Alternative Quantity Oxygen delivery system Positive pressure and demand valve Pocket mask Oxygen delivery system with bag valve mask device Minimum: 1 large adult, 1 child 1 per employee Automated electronic defibrillator(AED) Many 1 AED Syringes for drug administration Plastic disposable syringes with needles 3x2 ml syringes with needles for parenteral drug administration Suction and suction tips High volume suction Large diameter, round ended suction tips Non electrical suction system Office suction system Minimum 2 Tourniquets Robber and Velcro tourniquet; rubber tubing spygmomanometer 3 torniquets and 1 spygmomanometer Magill intubation forceps Magill intubation forceps 1 pediatric Magill intubation forceps

10. Module two – secondary/ noncritical drugs and equipment Category Generic Drug Alternative Quantity Availability Anticonvulsant Midazolam diazepam 1x5 ml vial 5 mg/ml Analgesic Morphine sulphate Meperidine 3x1 ml ampules 10 mg/ml Vasopressor Phenylephrine 3x1 ml ampules 10 mg/ml Antihypoglycem ic 50% dextrose Glucagon 1 vial 50 ml ampule Corticosteroid Hydrocortisone sodium succinate Dexamethasone 2x2 ml mix- o – vial 50 mg/ml Antihypertensive Esmolol Propranolol 2x100 mg/ml vial 100 mg/ml Anticholinergic Atropine Scopolamine 3x1 ml ampules 0.5 mg/ml Respiratory stimulant Aromatic ammonia 2 boxes 0.3 ml/vaporole Antihypertensive Nifedipine 1 bottle 10mg/capsule

11. Module three – Advanced Cardiac Life Support (ACLS) : essential drugs Category Generic Drug Alternative Quantity Availability Cardiac Arrest epinephrine 3x10 ml preloaded syringes 1:10,000 (1mg/10ml syringe) Analgesic Morphine sulphate N 2 O – O 2 3x1 ml ampules 10 mg/ml Antidysrhythmic Lidocaine Procainamide 1 preloaded syringe and 2x5 ml ampules 100 mg/ syringe Symptomatic Bradycardia Atropine Isoproterenol 2x10 ml syringes 1.0 mg/10 ml Paroxysmal Supraventricular Tachycardia verapamil 2x4 ml ampules 2.5 mg/ml

12. Module four – antidotal drugs Category Generic Drug Alternative Quantity Availability Opioid antagonist Naloxone nalbuphine 2x1 ml ampules 0.4 mg/ml Benzodiazepine antagonist Flumazenil 1x 10 ml vial 0.1 mg/ml Anticholinergic toxicity Antiemergence delirium Physostigmine 3x2 ml ampules 1 mg/ml

13. RESPIRATORY DISTRESS Asthma

14. ASTHMA ▶ In 1830 Eberle, a Philadelphia physician, defined it as “paroxysmal affection of the respiratory organs, characterized by great difficulty of breathing, tightness across breast, and a sense of impending suffocation, without fever or local inflammation.” ▶ Today it is defined as “a chronic inflammatory disorder that is characterized by reversible obstruction of the airways.” Stanley F Malamed – Med emergencies in the dental office : 8 th Ed

15. Predisposing factors: Extrinsic or allergic asthma, ▶ The allergens may be airborne – house dust, feathers, animal dander, furniture stuffing, fungal spores, or plant pollens. ▶ Food and drugs – cow’s milk, egg, fish, chocolate, shellfish, tomatoes, penicillins, vaccines , asprin, and sulfites. ▶ Type I hypersensitivity reaction – Ig E antibodies produced in response to allergen ▶ Approximately, 50% asthmatic children become asymptomatic before reaching adulthood Stanley F Malamed – Med emergencies in the dental office : 8 th Ed

16. Intrinsic or nonallergic, idiosyncratic, nonatopic asthma: ▶ Usually develops in adult age > 35 years ▶ Non – allergic factors – respiratory infection (viral infection is more common causative factor), physical exertion, environmental and air pollution, and occupational stimuli ▶ Psychological and physiologic stress can also contribute to asthmatic episodes in susceptible individuals ▶ Acute episodes are usually more fulminant and severe than those of extrinsic asthma. Long- term prognosis also less optimistic. Mixed asthma: ▶ Combination of extrinsic and intrinsic asthma. Major precipitating factor is respiratory tract infection. Stanley F Malamed – Med emergencies in the dental office : 8 th Ed

17. Status asthmaticus: ▶ More severe clinical form ▶ Experience wheezing, dyspnea, hypoxia ▶ Refractory to 2 – 3 doses of β- adrenergic agents ▶ If not managed adequately, patient may die due to respiratory distress Prevention: Medical history regarding ▶ Lung diseases ▶ Allergies to drugs, food, medication, latex . ▶ Usage of drugs, medications, natural remidies . Stanley F Malamed – Med emergencies in the dental office : 8 th Ed

18. H istory: ▶ Asthma? ▶ Type extrinsic or intrinsic? ▶ Age of onset ▶ History of acute episodes ▶ Precipitating factor ▶ Management Stanley F Malamed – Med emergencies in the dental office : 8 th Ed

19. Commonly prescribed drugs for the management: Bronchodilators: Sympathomimetic: ▶ Albuterol ▶ Salmeterol ▶ Metaproterenol ▶ Levalbuterol ▶ Epinephrine ▶ Theophylline ▶ Aminophylline anticholinergic: ▶ Ipratropium Corticosteroids: ▶ Beclomethasone , Triamcinolone, Flunisolide ▶ Mometasone , Fluticasone, Budesonide Antimediator: Cromolyn sodium, Nedocromil sodium Stanley F Malamed – Med emergencies in the dental office : 8 th Ed

20. Dental therapy considerations: ▶ Stress reduction protocol in case of emotional stress ▶ Contraindication of barbiturates and opioids as increase the risk of bronchospasm ▶ Some inhalational anesthetics like ether irritates respiratory mucosa ▶ Special care should be taken while prescribing analgesics ▶ Some patients are sensitive to bisulphites, local anesthesia is contraindicated Stanley F Malamed – Med emergencies in the dental office : 8 th Ed

21. Clinical manifestations: ▶ Feeling of chest congestion ▶ Cough, with or without sputum production ▶ Wheezing ▶ Dyspnea ▶ Patient wants to sit or stand up ▶ Use of accessory muscles of respiration ▶ Increased anxiety and apprehension ▶ Tachypnea (>20 - >40 in severe cases) ▶ Rise in B.P ▶ Increase in heart rate (>120 bpm in severe cases) Only in respiratory distress ▶ Diaphoresis ▶ Agitation ▶ Somnolence ▶ Confusion ▶ Cyanosis ▶ Supraclavicular and intercostal retraction ▶ Nasal flaring Stanley F Malamed – Med emergencies in the dental office : 8 th Ed

22. Pathophysiology: ▶ Neural control of airways ▶ Airway inflammation ▶ Immunological responses ▶ Bronchospasm ▶ Bronchial wall edema and hypersecretion of mucous glands ▶ Breathing Oxford textbook of Medicine : 5 th Edition

23. Management: Recognize problem (respiratory distress, wheezing) Discontinue dental treatment Activate office emergency team P – Position, usually upright with arms thrown forward A → B → C – Assess and perform basic life support as needed D – Definitive care: Administer O 2 Administer bronchodilator via inhalation (Episode terminates) (episode continues) Dental care may continue Discharge patient Hospitalize or discharge patient, per Activate EMS Administer parenteral drugs EMS recommendation Additional considerations: Sedatives which depress respiratory system and central nervous system are absolutely contraindicated. 5mg IV or IM diazepam may be indicated to decrease anxiety. Stanley F Malamed – Med emergencies in the dental office : 8 th Ed

24. Stanley F Malamed – Med emergencies in the dental office : 8 th Ed

25. SEIZURES Types: Causes: ▶ Congenital abnormalities ▶ Perinatal injuries ▶ Metabolic and toxic disorders ▶ Head trauma ▶ Tumors ▶ Vascular diseases ▶ Degenerative disorders ▶ Infectious diseases Partial seizures Generalized seizures Simple partial Absence seizures (true petitmal) Complex partial Myoclonic seizures Partial seizures evolving to generalized tonic – clonic Tonic – clonic seizures Unclassified epileptic seizures Stanley F Malamed – Med emergencies in the dental office : 8 th Ed

26. Predisposing factors: ▶ Hypoxia , hypoglycemia, hypocalcemia ▶ Flashing lights, fatigue, decreased physical health, a missed meal, alcohol ingestion, physical or emotional stress, sleep and menstrual cycle Prevention: ▶ Care in selection of LA agent & use of proper technique ▶ Medical history questionnaire about fainting spells, seizures ▶ Dialogue history about previous experience of seizures, onset, duration, management Dental therapy considerations: ▶ Conscious sedation – N 2 O – O 2 & benzodiazepines Stanley F Malamed – Med emergencies in the dental office : 8 th Ed

27. Clinical manifestations: ▶ Simple partial seizure – individual remains conscious while a limb jerks for several seconds ▶ Complex partial seizures – altered consciousness with altered behavioral patterns (automatisms) like some uncoordinated purposeless activities (lip smacking, chewing or sucking) ▶ Absence seizure – sudden immobility and a blank stare and minor facial clonic movements Stanley F Malamed – Med emergencies in the dental office : 8 th Ed

28. ▶ Tonic- clonic seizure – preictal phase: ↑ in anxiety and depression , appearance of aura and soon loses consciousness, a series of myoclonic jerks occur (epileptic cry) ↑ HR, B.P, bladder pressure, piloerection, glandular hypersecretion, mydriasis, apnea Ictal phase: series of generalized skeletal muscle contractions progresses to a extensor rigidity of extremities and trunk – tonic component Generalized clonic movements, heavy stertorous breathing, alternate muscle relaxation and violent flexor contractions – clonic component Postictal phase: tonic – clonic movements cease, breathing returns to normal, consciousness gradually returns Stanley F Malamed – Med emergencies in the dental office : 8 th Ed

29. Pathophysiology: Intrinsic intracellular and extracellular metabolic disturbances in neurons of epileptic patients Excessive and prolonged depolarisation ↑ in neuronal permeability to sod. And pot. Ions Ach. & GABA sustained membrane depolarization followed by local hyper polarization This abnormal discharge propagated through neuronal pathways and partial seizure becomes generalized Prusinski , L., Fundamentals of Corticosteroid Therapy, Oral Medicine Department, Nation Naval Dental Center , Bethesda, MD, 1997.

30. Management of petitmal seizures: P – position patient with feet elevated Seizure ceases: reassure patient seizure continues (> 5 min) Allow patient to recover before discharge A → B → C – Assess and perform BLS Stanley F Malamed – Med emergencies in the dental office : 8 th Ed

31. Management of tonic clonic seizure: Prodromal phase Discontinue dental treatment Ictal phase P – Position patient in supine position with feet elevated Activation of EMS A → B → C – Assess and perform basic life support as needed D – Definitive care Protect patient from injury Post ictal phase P – Position patient in supine position with feet elevated A → B → C – Assess and perform basic life support as needed D – Definitive care Administer O 2 Monitor vital signs Reassure patient and permit recovery Discharge patient To hospital To home To physician Stanley F Malamed – Med emergencies in the dental office : 8 th Ed

32. C onclusion Prompt recognition and efficient management of medical emergencies by a well- prepared dental team can increase the likelihood of a satisfactory outcome. The basic algorithm for managing medical emergencies is designed to ensure that the patient’s brain receives a constant supply of blood containing oxygen.

33. References ▶ Oxford textbook of Medicine : 5 th Edition ▶ Malamed, Stanley, Medical Emergencies in the Dental Office, 8th Ed. Mosby. ▶ Prusinski, L., Fundamentals of Corticosteroid Therapy, Oral Medicine Department, Nation Naval Dental Center, Bethesda, MD, 1997.