Should Epinephrine be used during Sudden Cardiac Arrest? (Dental Office)
Since epinephrine increases perfusion, and perfusion is the entire purpose of performing CPR (getting as much oxygenated blood to the brain as possible), I recently asked Dr. Stanley F. Malamed, Professor of Anesthesia & Medicine, University of Southern California, if a dentist should auto-inject a patient suffering from cardiac arrest with epinephrine? And if so, where?
“Intracardiac epinephrine is NO LONGER USED, even in medicine. Too many errors, as in injecting the epi into the myocardium, not into the chamber of the heart. In SCA epinephrine is administered either intravenously or intraosseously (e.g. EZ-IO). Endotracheally administered epinephrine is not longer thought to be the route of choice. Too many problems there too.
Giving the drug IM in the vastus lateralis or mid-deltoid would be of little practical value during SCA as there is no peripheral circulation in the absence of chest compression and having been administered IM even with chest compression the uptake would be entirely too slow.”
In the case of Sudden Cardiac Arrest in a dental chair, we should not use the epinephrine from our Dental Drug Kit. Stick with compressions, respiration's and certainly defibrillation. For more information on Emergency Medical Kits, contact First Responder Educational Services www.FRES-CPR.com
Dr. Stanley F. Malamed is Professor and Chief of Anesthesia & Medicine, University of Southern California, and lectures internationally on Medical Emergencies in the Dental Office.
Thursday, December 10, 2009
Monday, September 28, 2009
The most common dental medical emergency
What is the most common dental medical emergency?
Thankfully syncope or fainting. I say thankfully because syncope is generally short in duration and having very few side effects (a bumped skull being about the worst). Usually the patient regains consciousness in about 10 to 15 seconds and often doesn't even remember the episode.
A few Facts;
50% of fainting occurs just before or during the administration of L.A.
The patient (usually a big construction worker!) sees the needle...knows it's coming, tenses up, holds his breath...and goes limp. The reason for this is simple; The brain is being deprived of blood. When a person tenses up, blood is constricted by the muscle tissues, and the patient also holds their breath in an attempt to 'take the pain' of the injection.
The easiest way to avoid syncope in the dental chair, is to drop the chair into the supine position(horizontal with feet slightly elevated above the head) just prior to giving your injection. This way blood flows to the brain and the dentist has a clearer shot, so everybody wins.
About 25% of fainting patients do so when standing up immediately after a procedure. Again, this is due to a momentary drop in the amount of blood being distributed to the brain when the patient gets up. The best way to avoid this is to elevate the back of the chair and have the patient sit for a moment. (about as long as it takes them to rinse...If you catch my drift...) Then help them stand. In rare cases, you may need to use an ammonia inhalant to wake the patient from slumber land, and administering oxygen for a few minutes will also help.
You will notice that I have not mentioned over injecting a patient, or CNS depressant overdose or stroke. These events are not common in the dental office, but when they do occur, are life threatening and require advanced medical attention immediately.
The second most common reason for fainting is hypoglycemia, or low blood sugar. This can be more serious and will be discussed in a future blog post. For more information go to www.CLAMmedical.com to read more on medical emergencies in the dental office.
Thankfully syncope or fainting. I say thankfully because syncope is generally short in duration and having very few side effects (a bumped skull being about the worst). Usually the patient regains consciousness in about 10 to 15 seconds and often doesn't even remember the episode.
A few Facts;
50% of fainting occurs just before or during the administration of L.A.
The patient (usually a big construction worker!) sees the needle...knows it's coming, tenses up, holds his breath...and goes limp. The reason for this is simple; The brain is being deprived of blood. When a person tenses up, blood is constricted by the muscle tissues, and the patient also holds their breath in an attempt to 'take the pain' of the injection.
The easiest way to avoid syncope in the dental chair, is to drop the chair into the supine position(horizontal with feet slightly elevated above the head) just prior to giving your injection. This way blood flows to the brain and the dentist has a clearer shot, so everybody wins.
About 25% of fainting patients do so when standing up immediately after a procedure. Again, this is due to a momentary drop in the amount of blood being distributed to the brain when the patient gets up. The best way to avoid this is to elevate the back of the chair and have the patient sit for a moment. (about as long as it takes them to rinse...If you catch my drift...) Then help them stand. In rare cases, you may need to use an ammonia inhalant to wake the patient from slumber land, and administering oxygen for a few minutes will also help.
You will notice that I have not mentioned over injecting a patient, or CNS depressant overdose or stroke. These events are not common in the dental office, but when they do occur, are life threatening and require advanced medical attention immediately.
The second most common reason for fainting is hypoglycemia, or low blood sugar. This can be more serious and will be discussed in a future blog post. For more information go to www.CLAMmedical.com to read more on medical emergencies in the dental office.
The 7 Drugs you need in a medical emergency
Don't Create Liability (by trying to Reduce it)
Being a responsible dental practitioner, you realize that it is necessary to have an up to date emergency drug kit immediately available in the event a medical emergency should occur. Did you know however that having certain drugs in your kit actually creates liability and malpractice exposure?
What to Avoid
If you own a commercially available boxed drug kit, it likely contains drugs not intended for the general dental practitioner; Talwin, Tigan, Atropine etc., which are specialized medications used to 'treat' a patient, not 'stabilize' a patient. Your job as a practitioner is to stabilize a patient or Keep Them Alive - until EMS arrives. Simply owning these meds in your dental medical emergency drug kit implies a proficiency in using them. If you are not familiar with those little glass ampules, you would be well advised to remove them from your kit and dispose of them immediately.
Stick with These
Here are the ONLY 7 Drugs a dental practitioner should have (and be familiar with):
- Epinepherine .30mg (adult) and .15mg (child) in auto-injector form
- Diphenhydramine I suggest auto-injectors in the event allergic reaction is so severe that the patients airway becomes swollen shut and can't swallow liquid or pill form.
- Albuterol Inhaler For respiratory issues.
- Nitroglycerin Sublingual tablets in the event patient forgot his.
- Aspirin Tabs For onset of cardiac arrest
- Insta-Glucose For hypoglycemia (The second leading cause of unconsciousness)
- Supplemental Oxygen Portable tank for nearly any emergency
*Ammonia inhalants are also handy in the event of syncope (Fainting) but you should level back the chair first, that usually is all that is needed.
Take this Course
I strongly suggest attending Dr. Stanley Malameds 'Medical Emergencies in the Den
tal Office' course when it is available through your dental association or next conference. I have attended it on several occasions and he not only explains how and when to use them, but also sends home the message that the other meds are unnecessary and a waste of money. Dr. Malamed also has a book and DVD out by the same name, but you will get more from attending the course.
Please have a look at http://www.clammedical.com/ our drug kit contains only those medications recommended, all in pre-loaded devices for ease of use in a medical emergency, and it is so compact that it fits in your defibrillator carry case. Our site also has supporting documents from the ADA and other associations that urge dental practitioners to follow the same advice.
About the Author;
John Alibrandi is the Chief Training Officer for First Responder Educational Services which provides emergency medical training to dental offices, law enforcement agencies, universities and USCG Captains around the United States.
For more information, please visit http://www.fres-cpr.com/
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