Professional Documents
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Medical Emergencies CH 10-15
Medical Emergencies CH 10-15
RESPIRATORY RESPIRATORY
DISTRESS: GENERAL DISTRESS
CONSIDERATIONS
1
GENERAL CONSIDERATIONS
2
3
GENERAL CONSIDERATIONS
▪ The primary cause of airway obstruction is mechanical - the tongue falling into
the hypopharynx as skeletal muscle tone is lost
▪ Two steps of basic life support - A (airway) and B (breathing) - are designed to
manage this problem
4
PREDISPOSING FACTORS
5
PREDISPOSING FACTORS
6
PREDISPOSING FACTORS
7
PREVENTION
8
CLINICAL MANIFESTATIONS
9
CLINICAL MANIFESTATIONS
▪ For this reason, the doctor managing the situation must maintain an
appearance of being calm and in control of the situation at all times
10
CLINICAL MANIFESTATIONS
▪ The clinical symptoms of breathing difficulty and the sounds associated with it
will vary according to the cause of the problem.
▪ Individuals suffering heart failure and pulmonary edema often cough and
produce other sounds associated with pulmonary venous congestion.
11
PATHOPHYSIOLOGY
12
PATHOPHYSIOLOGY
13
PATHOPHYSIOLOGY
▪ Clinical signs and symptoms exhibited during the acute asthmatic attack are
related in large part to the restricted exchange of O2 and carbon dioxide in
the lungs
▪ Patients with heart failure usually mention respiratory distress as one of their
first symptoms.
14
PATHOPHYSIOLOGY
▪ The chronic inability of the lungs to adequately oxygenate venous blood and
the accompanying overuse of the available O2 produce respiratory distress
during heart failure.
15
PATHOPHYSIOLOGY
▪ The site of origin of this disorder is the mind (brain) of the patient, and its
clinical signs and symptoms are produced by an alteration in the chemical
composition of the blood.
16
PATHOPHYSIOLOGY
17
PATHOPHYSIOLOGY
▪ The level at which the airway becomes obstructed determines the severity of
the situation and, to some degree, the manner in which it is managed.
▪ If the object enters into either the right or left main-stem bronchi, the resulting
situation is critical but not immediately life threatening.
18
PATHOPHYSIOLOGY
▪ Foreign bodies most often enter into the right main-stem bronchus because of
the angle at which it branches off of the trachea.
▪ In this situation, all or part of the right lung is excluded from ventilation, but
the patient can still maintain adequate ventilation with the left lung. The patient
requires urgent medical intervention, but the condition usually is not
immediately life threatening.
19
PATHOPHYSIOLOGY
▪ In contrast, if the foreign object becomes impacted in the trachea, total airway
obstruction ensues - an acutely life-threatening situation.
20
MANAGEMENT
21
MANAGEMENT
22
MANAGEMENT
23
MANAGEMENT
24
MANAGEMENT
25
MANAGEMENT
▪ Step 5: D (definitive care). Response of the victim to the steps of basic life
support determines additional management.
▪ Step 5a: monitoring of vital signs. The individual’s blood pressure, heart rate
(pulse), and respiratory rate should be monitored at frequent intervals (at least
every 5 minutes) throughout the episode and recorded in a permanent
record.
26
MANAGEMENT
▪ Step 5b: definitive management of anxiety. The doctor should keep the
patient as comfortable as possible and begin to manage anxiety by speaking
calmly but firmly to the patient.
▪ The patient’s collar or other tight garments (that might restrict breathing) may
be loosened, enabling the patient to breathe more easily (even if the “ease” in
breathing is purely psychological).
27
MANAGEMENT
▪ Step 5d: activate emergency medical services, as needed. At any time during
the episode of respiratory distress, the doctor may activate emergency
medical services, if indicated
28
29
CHAPTER 11
FOREIGN BODY
AIRWAY OBSTRUCTION
30
INTRODUCTION
▪ Because of its frequently sudden and critical nature, acute foreign body
airway obstruction (FBAO) must be recognized and managed quickly.
▪ During dental treatment there is great potential for small objects to drop into
the posterior portion of the oral cavity and subsequently into the pharynx
31
INTRODUCTION
▪ In the conscious dental patient, chances are that any object lost in the
pharynx will be swallowed and pass into the esophagus or will be recovered
after being coughed up, so that the actual incidence of acute airway
obstruction or aspiration into the trachea, bronchi, and lungs is low.
▪ A high probability also exists that any object entering the airway will be small
enough in diameter to pass through the larynx (the narrowest portion of the
upper airway in the adult) without causing obstruction
32
INTRODUCTION
▪ The possibility does exist, however, that a foreign object may become lodged
in the larynx, completely obstructing the trachea.
▪ All dental office personnel should become familiar with proper management
of FBAO.
33
INCIDENCE
▪ The National Safety Council reported that 4600 individuals in the United
States died as a result of acute airway obstruction in 2009.
▪ More than 90% of deaths from foreign body aspiration in the pediatric age
group occur in children younger than 5 years; 65% of those deaths occur in
infants.
34
INCIDENCE
▪ Commonly aspirated items include hot dogs, rounded candies, nuts, grapes,
coins, toys, and other hard, colorful objects.17–20 Baby aspirin, with a
diameter of 7.5 mm, has obstructed airways and caused subsequent deaths in
several young children. (The diameter of the glottic opening in a 2-year-old is
about 6.5 mm.)
35
PREVENTION
▪ When objects are swallowed, they usually enter the gastrointestinal (GI) tract.
36
PREVENTION
▪ During the act of swallowing, the epiglottis seals the tracheal opening so that
liquid and solid materials enter the esophagus, not the trachea.
▪ The esophagus is the most likely site in the GI tract for objects to become
impacted because of its nature - the esophagus is a collapsed tube through
which liquids and solids are forced
37
38
CHAIR POSITION
▪ The supine position, which is recommended as a means of preventing
syncope, becomes detrimental to a patient who must use the body of the
tongue when a “dropped” foreign object is being maintained tenuously
against the roof of the mouth.
▪ If equipment is not readily available chairside to retrieve the object, the patient
should be turned onto his or her side and leaned into a head-down
(Trendelenburg*) position with the upper body hanging over the side of the
dental chair
39
The patient should turn to the
side and bend into a head-down
position with the upper body
over the side of the dental chair
in cases of a swallowed object.
40
DENTAL ASSISTANT AND SUCTION
▪ When an object falls free and is in danger of being swallowed, the assistant
may have available one or more devices with which to retrieve it, such as
pickup forceps and a hemostat.
41
DENTAL ASSISTANT AND SUCTION
▪ Saliva ejectors are not always useful in foreign body removal because the
force of the suction may not be great enough to grasp the object.
42
TONGUE GRASPING FORCEPS
43
LIGATURE
▪ The use of ligature (dental floss) can aid in the prevention of aspirated or
swallowed objects and in their retrieval from the posterior regions of the oral
cavity and pharynx
44
FIGURE 11-10 A, Cotton roll without floss. B,
Cotton roll with floss.
45
MAGILL INTUBATION FORCEPS
▪ The Magill intubation forceps (Figure 11-5), which is suggested for the basic
emergency kit, is designed to facilitate retrieval of large and small objects
from the posterior regions of the oral cavity and pharynx
46
▪ Magill intubation
forceps should be
included in the
office emergency
kit.
47
PROPER USE OF THE MAGILL INTUBATION FORCEPS
48
NO OTHER DEVICE, INCLUDING PICKUP FORCEPS (COTTON PLIERS)
OR HEMOSTATS, IS DESIGNED FOR RETRIEVAL OF OBJECTS.
49
MANAGEMENT
▪ The chair should be moved into a more reclined position (e.g., into the
Trendelenburg position, if possible) while the assistant picks up the Magill
intubation forceps.
▪ The Trendelenburg position allows gravity to move the object closer to the
anterior portion of the oral cavity, where it may be visible, aiding in its retrieval
with the Magill intubation forceps
50
MANAGEMENT
51
MANAGEMENT
▪ If the object cannot be seen (i.e., if the patient “swallows” it), radiographs are
warranted to determine its location; the patient should not be permitted to
leave the office without arrangements being made for these radiographs.
▪ Because clinical signs and symptoms do not always indicate whether the
object has entered the GI or respiratory tract, the doctor should escort the
patient (if feasible) to the emergency department of a local hospital or to a
radiology laboratory.
52
Anteroposterior view of the chest demonstrating a
rubber prophylaxis cup (arrow).
53
Gold crown that was aspirated into the left lung of the patient.
54
MANAGEMENT
55
MANAGEMENT
▪ Usually, the signs and symptoms exhibited by the patient help determine if the
object has entered into the trachea.
▪ More than 90% of patients who aspirate exhibit these signs and symptoms
within 1 hour of aspiration.
▪ A few patients may experience a time lag as long as 6 hours before symptoms
become evident
56
MANAGEMENT
▪ In situations in which the foreign body presumably enters the trachea, a well-
defined protocol should be followed, beginning with ensuring that the patient
does not sit up (sitting up may propel the object deeper into the trachea or
bronchi).
▪ The patient should be placed into the left lateral decubitus position with the
head down
57
MANAGEMENT
▪ The normal cough reflex is powerful and in many cases adequate to expel the
aspirated object.
58
MANAGEMENT
59
RECOGNITION OF AIRWAY OBSTRUCTION
▪ Acute upper-airway obstruction in the conscious person occurs most often while the
patient is eating. In adults, meat is the most common cause of obstruction
▪ Several common factors are identified in cases of the so-called cafe coronary
syndrome, including:
60
MANAGEMENT
▪ There are two categories of foreign body airway obstruction: complete and
partial obstruction.
61
COMPLETE AIRWAY OBSTRUCTION
62
The victim clutches the neck, demonstrating the
recommended universal distress signal for an obstructed
airway.
63
COMPLETE AIRWAY OBSTRUCTION
64
PARTIAL AIRWAY OBSTRUCTION
65
BASIC AIRWAY MANEUVERS
66
BASIC AIRWAY MANEUVERS
67
BASIC AIRWAY MANEUVERS
▪ Step 1: P (position). The patient should be placed into the supine position
with the feet elevated slightly
▪ Step 2: C (circulation). Check for pulse, if victim is unconscious, for not more
than 10 seconds. If no pulse or if pulse is doubtful, start chest compressions.
If pulse is present, continue to step 3.
68
SUPINE POSITION
69
BASIC AIRWAY MANEUVERS
70
BASIC AIRWAY MANEUVERS
https://www.youtube.com/watch?v=Y0KMpF5ztxA
71
BASIC AIRWAY MANEUVERS
▪ Step 4a: jaw-thrust maneuver, if indicated. The rescuer places his or her fingers behind the
posterior border of the ramus of the victim’s mandible displacing the mandible anteriorly
while tilting the victim’s head backward and opening the mouth
https://www.youtube.com/watch?v=6UeMuN0TxBU
72
BASIC AIRWAY MANEUVERS
▪ Step 5: A + B. Repeat step 4, if necessary.
▪ When these steps are performed properly but the airway remains obstructed
(diagnosed by aphonia, suprasternal retraction, and continued absence of
“hearing and seeing”), the rescuer should consider the probability that the
obstruction is located in the lower airway (larynx or trachea) and proceed
immediately to establish an emergency airway
73
EMERGENCY AIRWAY
74
EMERGENCY AIRWAY
▪ The American Heart Association and American Red Cross recommend the
abdominal thrust when lower-airway obstruction is a possibility, a situation
responsible for 4600 deaths in 2009.
75
ESTABLISHING AN EMERGENCY AIRWAY WHEN A PATIENT’S AIRWAY
IS OBSTRUCTED
▪ Victim of a partial airway obstruction who is capable of forceful coughing and
is breathing adequately (i.e., with no evidence of cyanosis or duskiness)
should be left alone.
76
ESTABLISHING AN EMERGENCY AIRWAY WHEN A PATIENT’S AIRWAY
IS OBSTRUCTED
▪ The victim remains conscious as long as the cerebral O2 level of the blood is
sufficiently high.
77
BACK BLOWS
▪ When back slaps are performed on the infant, the infant is straddled over the
rescuer’s arm with the head lower than the trunk and with the head supported
by the rescuer’s firm hold on the infant’s jaw.
78
BACK BLOWS
▪ Using the heel of the hand, the rescuer delivers up to five back slaps forcefully
between the infant’s shoulder blades while resting the other hand on the thigh
(Figure 11-18).
▪ Each slap should be delivered with sufficient force to attempt to dislodge the
foreign body
79
The rescuer uses the heel of one hand to deliver up to five back
slaps forcefully between the shoulder blades of an infant.
80
ABDOMINAL THRUSTS AND CHEST THRUSTS
▪ Chest thrusts should be used for obese patients if the rescuer is unable to
encircle the victim’s abdomen.
▪ If the choking victim is in the late stages of pregnancy, the rescuer should use
chest thrusts instead of abdominal thrusts.
81
ABDOMINAL THRUSTS AND CHEST THRUSTS
▪ chest thrusts are recommended for infants because abdominal thrusts are
more likely to cause organ damage (e.g., to the liver or spleen).
82
ABDOMINAL THRUST (HEIMLICH MANEUVER)
▪ When signs of good (mild airway obstruction) air exchange are present (e.g.,
forceful cough, speech, wheezing between coughs), the rescuer should
encourage the victim to spontaneously cough and breathe.
83
ABDOMINAL THRUST (HEIMLICH MANEUVER)
▪ The rescuer should not interfere with the victim’s own efforts to expel the
foreign body but should remain with the victim monitoring the victim’s efforts
and condition.
84
ABDOMINAL THRUST (HEIMLICH MANEUVER)
85
ABDOMINAL THRUST (HEIMLICH MANEUVER)
▪ In the presence of severe airway obstruction, the rescuer should ask the
victim if he or she is choking.
▪ If the victim nods “yes” the rescuer identifies himself or herself as someone
who can help and asks for permission to attempt to relieve the obstruction.
86
CONSCIOUS VICTIM
▪ After the rescuer confirms that the airway is obstructed by asking “Are you
choking?” and “Can I help you?” and receives an affirmative reply (e.g., nod)
to both:
▪ 1. Kneel or stand behind the victim and wrap your arms around the victim’s
waist.
87
CONSCIOUS VICTIM
▪ 4. Place the thumb side of the fist against the victim’s abdomen. The hand
should rest in the midline, slightly above the umbilicus and well below the tip
of the xiphoid process
▪ 5. Grab your fist with your other hand and press your fist into the victim’s
abdomen with a quick, forceful upward thrust
88
CONSCIOUS VICTIM
89
CONSCIOUS VICTIM
90
UNCONSCIOUS VICTIM
▪ 1. Place the victim in the supine position and call for emergency medical
services (EMS) as soon as possible.
91
UNCONSCIOUS VICTIM
▪ 3. In the adult or child victim, each time you stop compressions to open the
airway (A) and deliver two breaths (B), open the mouth wide and look in for
the object. If the object is visible, remove it using a Magill intubation forceps,
cotton pliers, or fingers.
92
UNCONSCIOUS VICTIM
▪ 4. If the object is not visible continue BLS with chest compressions repeating
steps 2 and 3 until the object is removed or EMS arrives on scene and takes
over management of the situation
93
CHEST THRUST
94
CONSCIOUS VICTIM
95
CONSCIOUS VICTIM
▪ 2. Grasp one fist with the other hand, placing the thumb side of the fist on the
middle of the sternum, not on the xiphoid process or the margins of the rib
cage.
▪ 4. Perform backward thrusts until the foreign body is expelled or the victim
loses consciousness.
96
UNCONSCIOUS OBESE OR PREGNANT VICTIM
▪ 1. Place the victim in the supine position and contact EMS as soon as
possible.
97
UNCONSCIOUS OBESE OR PREGNANT VICTIM
▪ 3. In the adult or child victim, each time you stop compressions to open the
airway (A) and deliver two breaths (B), open the victim’s mouth wide and look
in for the object. If the object is visible, remove it using either a McGill
intubation forceps, cotton pliers, or fingers.
98
UNCONSCIOUS OBESE OR PREGNANT VICTIM
▪ 4. If the object is not visible, continue BLS with chest compressions, repeating
steps 2 and 3 until the object is removed or EMS arrives on scene and takes
over management of the situation.
99
A chest thrust on an unconscious obese or pregnant
victim.
100
101
102
PROCEDURES FOR OBSTRUCTED AIRWAYS IN INFANTS
103
https://www.procpr.org/training_video/conscious-infant-choking
104
▪ https://www.procpr.org/training_video/unconscious-infant-
choking
105
QUESTIONS?
106
HYPERVENTILATION
CHAPTER 12
107
INTRODUCTION
108
INTRODUCTION
109
PREDISPOSING FACTORS
110
PREDISPOSING FACTORS
111
PREVENTION
▪ Question 5 (Have you had problems with prior dental treatment?) offers a
patient the opportunity to mention prior bad dental office experiences or
dental fears.
112
PHYSICAL EVALUATION
▪ Shaking hands with the patient provides valuable information. Cold, wet
(clammy) hands usually indicate apprehension.
▪ The patient may appear either flushed or pale; in either case the forehead is
usually bathed with perspiration, and the patient may remark that the office is
unusually warm, regardless of its actual temperature.
▪ Fearful patients simply appear uncomfortable when they sit in dental chairs
and are overly concerned with the goings-on around them.
113
VITAL SIGNS
▪ The vital signs of apprehensive patients may deviate from the normal, or
baseline, values for that individual.
▪ Blood pressure is elevated, with the systolic pressure rising more than the
diastolic.
114
VITAL SIGNS
▪ the patient’s respiratory rate increases above the normal adult rate of 14 to 18
breaths per minute, whereas the depth of respiration may be either deeper or
more shallow than normal.
115
CLINICAL MANIFESTATIONS
116
PATHOPHYSIOLOGY
▪ Anxiety is responsible for both the increase in respiratory rate and depth and
the increase in the levels of the catecholamines, epinephrine and
norepinephrine, in the blood (a result of the “fight or flight” response).
117
MANAGEMENT
▪ The doctor and staff members must initially attempt to calm the patient.
▪ They themselves must remain calm throughout the episode so that they do
not exacerbate the situation
118
MANAGEMENT
▪ Step 1: terminate the dental procedure. The presumed cause of the episode
(e.g., a syringe, dental handpiece, or pair of forceps) should be removed from
the patient’s line of vision.
119
MANAGEMENT
120
MANAGEMENT
121
MANAGEMENT
▪ Step 4a: removal of materials from the mouth. All foreign objects, such as a
rubber dam, clamps, and partial dentures, should be removed from the
patient’s mouth and any tight bindings (e.g., a tight collar, tie, or blouse),
which may restrict breathing, loosened.
▪ Step 4b: calming of the patient. In a calm and relaxed manner assure the
patient that all is well.
▪ Attempt to help the patient regain control of his or her breathing by speaking
calmly.
122
MANAGEMENT
▪ Have the patient breathe slowly and regularly at a rate of about 4 to 6 breaths
per minute, if possible.
▪ This will allow the PaCO2 to increase, reducing the pH of the blood to near
normal and eliminating (slowly) any symptoms produced by respiratory
alkalosis.
123
MANAGEMENT
▪ Step 4c: correction of respiratory alkalosis. When the preceding steps are
ineffective, helping the patient to increase blood PaCO2 level is the next
objective.
▪ More realistically, the patient will be told to rebreathe exhaled air, which
contains an increased concentration of CO2.
124
MANAGEMENT
125
MANAGEMENT
▪ In addition to elevating PaCO2 levels, the warm exhaled air against the cold
hands will warm their hands, alleviating one of the more frightening symptoms
of hyperventilation.
▪ A full-face mask from an O2 delivery unit may also be used. However, care
must be taken not to administer O2 to the hyperventilating patient.
126
The hyperventilating victim cups
the hands together in front of
the mouth and nose as a means
of increasing the arterial carbon
dioxide tension (PaCO ).
2
127
MANAGEMENT
128
MANAGEMENT
▪ Dental treatment may continue at this time if both the doctor and the patient
are comfortable in doing so.
129
MANAGEMENT
▪ Step 6: discharge. After the episode has ended with all signs and symptoms
resolved, the patient may be discharged from the office as usual.
▪ If the doctor has any uncertainty about the patient’s recovery or if any CNS-
depressant drug was administered, a person with a vested interest in the
health and safety of the patient, such as a friend or relative, should be called
to take the patient home.
▪ An entry about the episode and its management should be placed in the
dental progress notes.
130
131
QUESTIONS?
132
ASTHMA
CHAPTER 13
133
GENERAL CONSIDERATIONS
134
GENERAL CONSIDERATIONS
▪ Approximately 18.9 million adult and 7.1 million children in the United States,
and more than 235 million persons worldwide, suffer from asthma
135
GENERAL CONSIDERATIONS
▪ Asthma is primarily a disease of young people; half of all cases develop before
the individual reaches 10 years of age, and another third before age 40 years
136
PREDISPOSING FACTORS
137
PREDISPOSING FACTORS
138
PATHOPHYSIOLOGY
139
PATHOPHYSIOLOGY
140
PATHOPHYSIOLOGY
141
142
143
144
145
146
MANAGEMENT ACUTE ASTHMATIC EPISODE (BRONCHOSPASM)
▪ Other positions are equally acceptable, based upon the comfort and preference of
the patient.
147
148
MANAGEMENT ACUTE ASTHMATIC EPISODE (BRONCHOSPASM)
▪ Step 4: calming of the patient. Many asthmatic patients, especially those with
histories of easily managed bronchospasm, will remain calm throughout the
episode.
▪ Others, primarily those with acute episodes that have been more difficult to
terminate, may exhibit varying degrees of apprehension.
149
MANAGEMENT ACUTE ASTHMATIC EPISODE (BRONCHOSPASM)
150
MANAGEMENT: ACUTE ASTHMATIC EPISODE (BRONCHOSPASM)
151
MANAGEMENT: ACUTE ASTHMATIC EPISODE (BRONCHOSPASM)
152
MANAGEMENT: ACUTE ASTHMATIC EPISODE (BRONCHOSPASM)
153
MANAGEMENT: ACUTE ASTHMATIC EPISODE (BRONCHOSPASM)
▪ Step 7: subsequent dental care. Once the acute episode is terminated, the
doctor should determine the cause of the attack.
▪ The planned dental treatment may continue at this visit if both the patient and
the doctor feel that it is appropriate.
154
MANAGEMENT: ACUTE ASTHMATIC EPISODE (BRONCHOSPASM)
▪ Such discharge is not usually a problem in cases of acute episodes that are
terminated quickly with bronchodilator therapy.
155
SEVERE BRONCHOSPASM
156
SEVERE BRONCHOSPASM
▪ Step 6c: call for assistance. When aerosolized bronchodilators fail to resolve
bronchospasm
157
SEVERE BRONCHOSPASM
158
SEVERE BRONCHOSPASM
▪ In other situations, the emergency personnel may determine that the patient
does not need hospitalization.
▪ In such cases a decision about how and when the patient may leave the office
(i.e., alone or escorted) should be made before the emergency personnel
depart.
159
160
161
QUESTIONS?
162
HEART FAILURE AND
ACUTE PULMONARY
EDEMA
CHAPTER 14
163
GENERAL CONSIDERATIONS
▪ Cardinal manifestations of heart failure are dyspnea and fatigue, which may
limit exercise tolerance, and fluid retention, which may lead to pulmonary
congestion and peripheral edema
164
PREDISPOSING FACTORS
▪ The tendency of heart failure to begin as left ventricular failure relates to the
disproportionate workload of, and the prevalence of cardiac disease in, the left
ventricle. Disease produces heart failure in one of two basic ways:
1. Increasing the workload of the heart. For example, high blood pressure increases
resistance to the ejection of blood from the left ventricle, increasing the workload of
the myocardium. Seventy-five percent of heart failure cases have a prior history of
high blood pressure.
2. Damaging the muscular walls of the heart through coronary artery disease or
myocardial infarction.
165
PREDISPOSING FACTORS
▪ Any factor that increases the workload of the heart may precipitate an acute
exacerbation of preexisting heart failure, which may result in acute pulmonary
edema.
▪ Acute pulmonary edema may occur at any time, but most often at night, after
the individual has been asleep for a few hours
166
PREDISPOSING FACTORS
▪ Of all children who develop heart failure, 90% do so within the first year of life
secondary to congenital heart lesions
167
PREVENTION
▪ The medical history questionnaire and the dialogue history are the best forms
of prevention.
168
169
170
171
THE ASA PHYSICAL STATUS CLASSIFICATION FOR HEART FAILURE
▪ ASA 1: The patient does not experience dyspnea or undue fatigue with
normal exertion.
▪ Comment: If all items of the medical history are negative, this patient may be
considered normal and healthy.
172
THE ASA PHYSICAL STATUS CLASSIFICATION FOR HEART FAILURE
▪ Comment: As with the ASA 1 patient, the ASA 2 patient may be managed
normally if the remainder of their medical history and physical examination
prove to be noncontributory.
173
DENTAL THERAPY CONSIDERATIONS
▪ ASA 3: The patient experiences dyspnea or undue fatigue with normal activities.
▪ Comment: This patient is comfortable at rest in any position but may demonstrate a
tendency toward orthopnea and have a history of paroxysmal nocturnal dyspnea.
▪ The ASA 3 patient with heart failure is at increased risk during dental treatment.
Before starting any treatment, medical consultation and use of the stress reduction
protocol and other specific treatment modifications should be given serious
consideration.
174
DENTAL THERAPY CONSIDERATIONS
▪ ASA 4: The patient experiences dyspnea, orthopnea, and undue fatigue at all
times.
▪ Comment: The ASA 4 patient represents a significant risk. Even at rest this
patient’s heart cannot meet the body’s metabolic requirements.
175
DENTAL THERAPY CONSIDERATIONS
176
177
178
PATHOPHYSIOLOGY
▪ Heart failure may develop whenever the heart labors for extended periods of
time against increased peripheral resistance (increased afterload), such as
occurs with high blood pressure or valvular defects (stenosis or insufficiency),
or prolonged, continuous demands for increased cardiac output (as occurs in
hyperthyroidism).
179
PATHOPHYSIOLOGY
180
MANAGEMENT
181
MANAGEMENT
▪ This position allows excess fluid within the alveolar sacs to concentrate at the
bases of the lungs, permitting a greater exchange of O2.
▪ If at any time the patient loses consciousness, that individual must be placed
in the supine position.
182
MANAGEMENT
183
MANAGEMENT
▪ Further medical management in the hospital may include phlebotomy, O2, and
drug therapy, such as digitalis and diuretics.
184
MANAGEMENT
▪ Step 5: calming of the patient. Dental personnel must reassure the patient
that they are making every effort to manage the problem and that they have
summoned emergency personnel.
185
MANAGEMENT
186
MANAGEMENT
▪ Step 7b: monitoring of vital signs. Vital signs, including blood pressure, heart
rate and rhythm, and respiratory rate, should be monitored and recorded
every 5 minutes.
▪ The blood pressure, heart rate, and respiratory rate increase in patients with
acute heart failure; these changes demonstrate the presence of extreme
apprehension and cardiac and pulmonary congestion.
187
MANAGEMENT
▪ In cases of acute pulmonary edema, the heart cannot adequately handle the
quantity of blood being delivered to it.
188
MANAGEMENT
189
190
QUESTIONS?
191
CHAPTER 15
RESPIRATORY DISTRESS:
DIFFERENTIAL
DIAGNOSIS
192
MEDICAL HISTORY
▪ Advantage may be taken of this by asking the patient about any previous
similar episodes.
193
MEDICAL HISTORY
194
AGE
▪ Respiratory distress in younger patients (under the age of 10) most commonly
is related to asthma (usually allergic asthma).
▪ Hyperventilation and heart failure are significantly less common in this age
group (children with severe, uncorrected, congenital heart defects may
demonstrate respiratory distress, but their medical history will have provided
the doctor with this information).
195
AGE
▪ Asthma may also occur in this age group, but in most instances, patients
already know that they suffer from this condition.
▪ Clinically significant heart failure is rarely seen before the age of 40 years.
196
SEX
▪ The incidence of hyperventilation, asthma, and heart failure does not differ
markedly between males and females
▪ The incidence of heart failure is slightly greater among males in any age
group than in females under the age of 70 years.
197
RELATED CIRCUMSTANCES
▪ In addition, stress causes the physical condition of patients with heart failure
to progressively deteriorate.
198
CLINICAL SYMPTOMS BETWEEN ACUTE EPISODES
▪ The patient with heart failure may exhibit clinical signs and symptoms at all
times, either during physical activity or at rest.
199
CLINICAL SYMPTOMS BETWEEN ACUTE EPISODES
200
POSITION
▪ The position of the patient at the onset of clinical symptoms is most relevant in
patients with heart failure.
201
POSITION
202
ACCOMPANYING SOUNDS
203
ACCOMPANYING SOUNDS
▪ Individuals with heart failure may also exhibit moist, wet respirations,
especially those suffering acute pulmonary edema, which is often associated
with a frothy, pink-tinged sputum and cough.
▪ Hyperventilating individuals breathe deeper and more rapidly than normal but
produce no accompanying abnormal sounds.
204
SYMPTOMS ASSOCIATED WITH RESPIRATORY DISTRESS
205
SYMPTOMS ASSOCIATED WITH RESPIRATORY DISTRESS
206
PERIPHERAL EDEMA AND CYANOSIS
▪ Patients with heart failure may exhibit peripheral edema and cyanosis.
207
PARESTHESIA OF THE EXTREMITIES
▪ Tingling and numbness of the fingers, toes, and perioral regions are
experienced during hyperventilation.
▪ These symptoms may also be present, but much less commonly, in milder
episodes of asthma and heart failure, produced by the patient hyperventilating
secondary to acute anxiety.
208
USE OF ACCESSORY RESPIRATORY MUSCLES
209
CHEST PAIN
210
CHEST PAIN
▪ Patients suffering asthma usually do not experience chest pain along with
their other clinical symptoms.
▪ When chest pain occurs in a patient with preexisting heart failure, it might be
associated with a concurrent acute myocardial infarction.
211
HEART RATE AND BLOOD PRESSURE
▪ Both heart rate and blood pressure usually increase during periods of
respiratory distress.
212
HEART RATE AND BLOOD PRESSURE
▪ Although both the systolic and the diastolic pressures increase during heart
failure, diastolic blood pressure is usually elevated to a greater degree;
therefore, the pulse pressure (systolic minus diastolic) narrows (to 40).
213
DURATION OF RESPIRATORY DISTRESS
214
DURATION OF RESPIRATORY DISTRESS
▪ Most asthma attacks will not resolve for a considerable period without drug
management; therefore, bronchodilator therapy is employed as soon as it is
available.
215
QUESTIONS?
216