EMERGENCY MEDICINE SUMMARY

COMMON EMERGENCIES
Syncope, Seizures, Allergic reactions, Cardiac events, Unresponsiveness,
Respiratory/cardiac arrest, Hypoglycemia
GENERAL PRINCIPLES
Prevention
o Get a good medical hx (meds and allergies)
Preparation: Plan for the worst case scenario
o Office personnel should be certified in CPR
o Have emergency equipment available and be familiar with it
o Dentists should ideally be ACLS certified
o Personnel should practice plan
SYNCOPE
20% of the general population will experience syncope
Benign causes: vasovagal syncope
Malignant causes:
o Cardiac issues: MI, arrhythmias, Allergic reaction, Hypovolemia,
Hypoglycemia, Pulmonary embolism, Aortic dissection, GI bleeding,
Ruptured ectopic pregnancy
Vasovagal syncope: Most common
o Precipitating factors: Pain, Fear, Sight of blood
o Caused by hypotension due to bradycardia and venous pooling.
o Symptoms: warmth, light-headedness, nausea, decrease in vision.
o Recovery should be rapid, and without confusion
Who to transfer to emergency department:
o Patients with precipitating symptoms:
Chest pain, Dyspnea, CNS deficits, Abdominal pain, Patients
who are found to be orthostatic
o Age 40 or older: increase risk of serious underlying cause
SEIZURES
Most commonly due to non-compliance with seizure medications.
Stress may trigger seizures in those with a history of them.
Hypoglycemia: seen in those on insulin or oral hypoglycemics.
Hyponatremia
Iatrogenic: Most often due to local anesthetic agents and epinephrine.
Treatment:
Protect patient from injury
Maintain airway
Provide high flow oxygen: use non-rebreather mask.
May use a bite block or padded tongue depressor to open the mouth.
Never stick your fingers in a seizing patients mouth
Call 911
Have bag-valve-mask available
Initiate IV
If patient is still seizing, administer 5-10mg of valium.
If an IV cannot be initiated, valium can be administered rectally
Coat needleless syringe with lubricant and administer medication as a
bolus rectally.
Be aware of injuries associated with the seizure.
Do not move the patient unless they are in danger.
Use caution- post-ictal patients can be confused and combative.
ALLERGIC RXNS AND ANAPHYLAXIS
Symptoms: can progress rapidly
Rashes: urticaria is red, splotchy, pruritic (itchy).
Airway compromise: tongue feels bigger, throat tightening, difficulty
swallowing, speech problems, stridor.
Dyspnea: wheezing due to bronchospasm
Hypotension
Gastrointestinal complaints
Mild reactions:
H1 Blockers: Benadryl, Allegra, Zyrtec, Claritin
H2 Blockers: Zantac, Pepcid, Axid
Major reactions:
Epinephrine: oropharyngeal edema and/or hypotension
Steroids
Treament:
o Airway, breathing, circulation
o IV access: large bore IV with normal saline
o Benadryl 50mg IV
Can administer IM if no IV access
o Pepcid 20mg IV
o If severe case, epinephrine 1:1000, 0.3mg SC
Coronary artery disease is relative contraindication
If patient hypotensive, may consider epinephrine 1:10,000
0.3mg IV SLOWLY.
CARDIAC PROBLEMS
Myocardial Infarction
Risk factors: hypertension, diabetes, hypercholesterolemia, family
history, smoking.
Symptoms:
o Chest pain: may radiate to arms, shoulder, neck, jaw, back. Pain
often described as a pressure or squeezing
o Associated symptoms: dyspnea, diaphoresis, nausea, vomiting,
palpitations, syncope-- symptoms vary!
Angina patients:
If a patient with a history of angina is having his typical chest pain in
its typical anginal pattern, and it is relieved by nitroglycerin, just
monitoring patient ok.
Any change in pain, pattern warrants ER referral.
Be suspicious of a patient presenting with jaw pain- could be of cardiac
origin.
Clues to fact that it is cardiac:
No intra-oral or facial etiology
Unclear pain distribution
Associated chest discomfort, dyspnea, nausea, vomiting, diaphoresis,
abnormal vital signs, look like FTD (Fixing To Die).
Treatment:
ABCs
Call 911-only transport by EMS!!
Oxygen
Monitor
IV line
Aspirin if available
Nitroglycerin if available and blood pressure stable
CARDIAC ARREST
A-Airway
Check for foreign bodies
Perform jaw thrust/chin lift
B-Breathing
If breathing, place on high flow oxygen
If patient not breathing, then ventilate patient using bag-valve-mask
or other adjunct
Ventilate at 12-20 breaths per minute.
Administer 100% oxygen
C-Circulation
Check a carotid pulse
If no pulse, start chest compressions
Start IV with normal saline in one antecubital fossa
If unresponsive:
Administer narcan 0.4mg and glucose D50, 25 grams IV
If no IV established, can administer narcan IM or glucagon 1mg IM.
HYPOGLYCEMIA
Patients usually on insulin or oral hypoglycemics
Patient often skips a meal prior to hypoglycemic episode.
If making a patient NPO prior to a procedure, be certain to adjust the insulin
dose. Have IV fluids with glucose on hand, such as D51/2NS.
If suspect patient is hypoglycemic, treat immediately.
If patient is awake, administer orange juice with sugar or oral glucose.
If patient has altered mental status:
If IV established, administer D50 25grams IV
If no IV, then administer glucagon 1mg IM (caution: vomiting)
All patients with hypoglycemic episode should eat a meal and be observed.
Patients should be referred to the emergency department if :
they are on oral hypoglycemics
the reason for the hypoglycemic episode is unclear
the patient does not return to baseline
CPR/ACLS
Airway control:
Jaw thrust, Chin lift, Maintain cervical spine immobilization if injury is
suspected.
Ventilate with:
Bag-valve-mask, Mouth-mask, Face shield
OXYGEN THERAPY
Nasal Cannula: 1-6 LPM--Provides 24-44%
Simple masks: 40-60%
Non-rebreather masks: 90-100%
Bag-valve-mask: 100%
You can never give too much oxygen, even if patient has COPD.
BASICA AIRWAY ADJUNCTS
Nasal trumpets: Lube them up; Bevel points medially
Oropharyngeal Aiways
Measure from lips to angle of jaw; Insert inverted and turn upright as
you reach the back of the tongue; Only tolerated in unconscious
patients without a gag reflex
ADVANCED AIRWAY TECHNQUES
Endotracheal Intubation: Cuffed tube passed through vocal cords utilizing
direct laryngoscopy and placed in the trachea, securing the airway
Alternate techniques: Nasotracheal, Digital, Fiberoptic, Lighted stylet,
Retrograde intubation, Combitube, LMA
SURGICAL AIRWAY TECHNIQUES
Needle cricothyrotomy: large bore IV catheter through the cricothyroid
membrane.
Surgical cricothyrotomy: 6.0 ETT placed through incision in anterior neck
and through the cricothyroid membrane
TRANSPORTING PATIENT TO ED
If you feel a patient is ill enough to be seen in the emergency department, he
should come by ambulance