Chronic complications of diabetes Microangiopathy - vessels affected - affects kidney and _____ - affect on kidney

- small blood vessels - eye, causes blindness - arteriolar nephrosclerosis

Cerebrovascular accident Two types - occurs on the surface of the brain within the subarachnoid space - occurs within the parenchyma of the brain Two major sources of hemorrhage

- subarachnoid - intracerebral - arterial aneurysms and hypertensive vascular disease

Test 2 Flashcards by Spencer Gross

What is the primary cause of decreased life expectancy in diabetes mellitus?

renal disease

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Blood glucose level of hypoglycemia?

Is the acute form life threatening?

50mg/dL

yes

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Chronic complications of diabetes

Arteriosclerosis

vessels affected
affect on kidney

large blood vessels

glomerulosclerosis

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Chronic complications of diabetes

Microangiopathy

vessels affected
affects kidney and _____
affect on kidney

small blood vessels
eye, causes blindness
arteriolar nephrosclerosis

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Diabetes Patiens

increased thirst
increased appetite
increase frequency of unination

polydipsia
polyphagia
polyuria

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Stress Protocol for Diabetes patients

appointment time
avoid?
Which type of diabetic patient is less prone to acute fluctuations in blood glucose levels?

early in the morning
long acting local anesthetic (so they can eat)
Type 2

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Clinical signs of TYPE 2 Diabetes

HYPERglycemia: 3 things

fruity breath
rapid heart rate
hypotensive

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Clinical signs of TYPE 2 Diabetes

HYPOglycemia (most common complication)
Early Stage: 3 signs
Advancing Early Stage: 3 signs
Late Stage: 3 signs

ES: diminished cerebral function, hunger Nausea

AES: sympathetic hyperactivity, skin cold/wet, behavior mimics alcohol intoxication

LS: unconsciousness, seizures, hypertension

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Body tries to regulate glucose at ____ to ____ mg/dL for normal brain function.

At what level does blood glucose exceed renal reabsorption and spill over into urine?

50-150

180

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Hyperglycemia

what causes metabolic acidosis?
what would the bloods pH be during this?
how does the body try and compensate? (special name)

tissues decrease use of ketones with increase in blood levels

7.3 and lower

hyperventilation (Kussmaul’s respirations)

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Management of a HYPERglycemic patient

P-
D-

P-supine

D-activate EMS, oxygen

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Management of a HYPOglycemic patient

Conscious responsive
P-
D-
discharge-

P-upright
D-orla glucose
can be discharged with home escort

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Management of a HYPOglycemic patient

Conscious Unresponsive
P-
D-
discharge-

P-upright
D-IV dextrose response in 5mins
IV/IM Glucagon 10-15mins

discharge to EMS

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Management of a HYPOglycemic patient

Unconscious
P-
D-
discharge-

p-supine
D-EMS, IV dextrose, IV/IM Glucagon, Epi .5mg

discharge to EMS

diabetic patient who behave bizarrely or lose consciousness should be managed as if they are HYPOglycemic until proven otherwise

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Usual cause of hypothyroidism?

type of disease?
frequency in MvsF
decade of greatest incidence 
End stage result
Avoid-

idiopathic atrophy of thyroid
Autoimmune
3-10x more in F
7th decade 
myxedema coma
sedatives and analgesics

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Clinical manifestations of hypothyroidism

Indications
nerve 2-
temp-
weight-
GI-
skin-
respiratory- 
cardio- 
Tongue-

N-parasthsia of median nerve (carpal tunnel) pseudomyotonic reflex (prolonged deep breaths)
T-cold/hypothermia
W-gain
GI-constipation
S-dry
C-bradycardia
Tongue-thick

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Clinical manifestations of hyperthyroidism

type of disease
common disease
frequency in MvsF
decade of greatest incidence
end stage
Avoid

autoimmune
Grave's
8xF
3rd-5th
thyroid storm 
atropine (use racemic epic instead), sedation less effective

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Clinical manifestations of hyperthyroidism

Indications
Weight-
GI-
Temp-
cardio 2-
skin-
eyes-

loss
loose stools
intolerance to heat/fever
tachycardia, wide pulse pressure 
warm, moist
exopthalamos

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Management of Hyper/Hypothyroid patients

P-
D-

conscious=upright, unconscious=supine

if consciousness doesn’t return with positioning, activate EMS, O2, IV infusion

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Cerebrovascular accident

definition
__ leading cause of death in US
frequency MvsF

focal neurological disorder caused by destruction of brain substance

3rd
M2:1

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Cerebrovascular accident

Two types

occurs on the surface of the brain within the subarachnoid space
occurs within the parenchyma of the brain

Two major sources of hemorrhage

subarachnoid
intracerebral
arterial aneurysms and hypertensive vascular disease

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What is a TIA

most resolve in ____min

transient ischemic attack, focal ischemic defeats that last less than 24hrs

15-60mins

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Cerebrovascular accident

time for maximal neurologic deficit improvement?
hint: same amount of time for dental treatment

6 months

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Cerebrovascular accident Clinical Manifestations

TIA
onset-
recovery-
symptoms 2: extremities, eyes

abrupt
2 to 10mins
transient numbness or weakness in extremities
transient monocular blindness

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Cerebrovascular accident Clinical Manifestations ``` Infarction onset- what precedes- symptoms -head -neuro 3: ```

- gradual, minuets to days - TIA - mild headache - paralysis on ONE side of face/body, slurred speech (aphasia), unequal pupils

Cerebrovascular accident Clinical Manifestations ``` Embolism onset- symptoms -head -balance % loss of consciousness ```

- abrupt seconds - violent headache - vertigo, nausea - 50%, high mortality with loss of consciousness

Cerebrovascular accident Management ``` P- conscious vs unconsciousness D- If TIA 1st occurrence: 2nd: ```

P -C: upright or semi supine -U: supine D- EMS, O2, NO NITROUS

Tonic-Clonic (most common) formally known: episode lasts:

grand mal | 1-3mins

Absence formally known: episode lasts: most common ages:

petit mal 5-10 secs 4-14yrs

``` Atonic also known as: abrupt loss of____ conscious? episode lasts: ```

drop attacks muscle tone yes less than 15sec

``` Clonic occurrence: ages: muscle movements episode lasts: what happens to individual once seizure stops? ```

``` rare all ages rhythmic muscles jerking few sec to min continue doing whatever they where doing ```

``` Myoclonic muscle movements: episode lasts: mental state: side of body: ```

shocklike jerks 1-2 seconds No change both sides

``` Tonic muscle movements: mental state: episode lasts: after episode: ```

stiffening of extremities consciousness preserved 20secs tired and confused

``` Simple partial mental state: episode lasts: Types 4: may be associated with _____ injury ```

remains alert less than 2 mins motor, sensory, autonomic, psychic Head injury

Complex partial (focal seizure with impairment) starts where in brain? common sign: episode lasts:

frontal lobe automatisms 30sec to 2mins

Status Epilepticus defined as: severe problem? most common precipitating factor:

seizure persisting longer than 30mins convulsive status is medical emergency failure to take anti epileptic drugs

Causes of Epilepsy Primary and % Secondary and %

idiopathic or genetic, 65% | everything else 35%

Secondary Causes of Epilepsy tumor common age: vascular age: febril age:

35-40 after 60 3months to 6yrs

Common method of preventions for dental therapy:

nitrous oxide

Clinical Manifestations Absence mental status:

complete suppression of all mental functions

Clinical Manifestations Generalized tonic-clonic Prodromal Phase noted change in: presence of ____ at onset Relates to ____ of brain

emotions aura relates to area of brain affected Olfactory auditory ect...

Clinical Manifestations Generalized tonic-clonic ``` Preictal phase what happens phase where most ____ happen respiratory sign: Autonomic chages FYI ```

lose consciousness and fall injuries epileptic cry- air expelled through partially closed glottis while diaphragm muscles spasm HR, bladder pressure, piloerection

Clinical Manifestations Generalized tonic-clonic Ictal Phase -Tonic sub phase -Clonic sub phase How does it end:

- skeletal phase - alternating muscular relaxation and violent flexor contractions - ends as respiratory movement returns

Clinical Manifestations Generalized tonic-clonic Postictal Phase - muscular phase - urinary/fecal - mental status

- muscular flaccidity - incontinence - amnesia, headache

Status Epilepticus As seizure progress patient develop - temp - cardio

- hyperthermia | - Tachycardia and dysrhythmias

If a GTCS Ictal phase lasts more than ____ call EMS

5min

FYI administer _______ to rule out hypoglycemia. If status epileptics call 911.

50% dextrose IV

ADRs that cannot be explained by any known pharmacologic or biochemical mechanism-

idiosyncrasy

Majority of adverse drug reactions are caused by what?

drug overdose 85%

How long does the clinical reaction continue for a drug overdose?

as long as blood level remains above threshold

Who is at a greater risk for adverse drug reactions?

young and old

As a general rule, drug doses should be decreased for patients under ____ and over ____

6yr and 65yrs

Explain why in relation to body weight, lean body weight has a higher tolerance than obese.

greater blood volume with lean compared to obese

Congestive heart failure patients show blood levels ____ those of healthy patients at same doses

How and why does pulmonary disease lead to increased risk of local anesthetic overdose?

increase CO2 retention causes respiratory acidosis which lowers the seizure threshold

True or False | Threshold for local anesthetic is lowered in patients who are overly stressed?

True

Local anesthetics with ___ levels of lipid solubility and protein binding have slower absorption into blood

higher

True or False | Blood level determined by concentration of the drug

False | Blood level determine by mg of drug given not concentration

Decreased liver function is a relative contraindication to ____ local anesthetics. Instead use _____ since it is poorly absorbed and has ____ water solubility.

amide benzocaine lower

Onset and duration of Drugs Intravascular: Excess dose: Slow biotransformation and or elimination Common signs and symptoms tend to be generally ____

Rapid gradual, 10mins slow, 90mins or more excitatory symptoms

Moderate to high blood levels of drugs leads to what type of seizure? what does it look like?

generalized tonic-clonic | period of CNS depression follows convulsive state

_____ and ____ overdose may appear initially as drowsiness and anystagmus before leading to unconsciousness or seizure activity

Lidocaine and mepivacaine

If a patient undergoes a rapid onset ADR from a mild overdose but recovers shortly, are we able to continue with treatment? Can they leave unescorted?

yes and yes

If a patient undergoes a delayed onset ADR from a mild overdose but recovers shortly, are we able to continue with treatment? Can they leave unescorted?

NO, escorted to hospital

Mild overdose with rapid delayed onset Diagnostic clues: 4 P D

``` 1 talkativeness 2 increased anxiety 3 facial twitch 4 increase HR BP and respiration P-confortable position D-O2, anticonvulsant ```

Severe Overdose Reaction with Rapid Onset When do signs and symptoms appear and what are they? P D

during or seconds after injection, Generalized tonic-clonic seizure P-supine D- EMS if any seizure with injection

Severe Overdose Reaction with Slow Onset When do signs and symptoms appear and what are they? P D

around 5mins, tonic-clonic seizure P-supine D-EMS if any seizure with injection

Noncardioselective _____ may result in overdose of Ep-

Beta blockers

Management of a Patient with Epinephrine overdose P D -market by If BP remains low administer_____

P-avoid supine D-activate EMS -markedly elevated blood pressure with headache and flushing Nitroglycerine with patient Upward, if signs persist take to hospital, if cease discharge

CNS depressant overdose Sedative hypnotics P CAB D

P-supine CAB- maintain airway, most important D-EMS

CNS depressant overdose ``` Opioid Diagnosis- P CAB D -give ```

``` Miosis P-Supine CAB- oxygenation D -EMS -give .1mg per min IV or.4mg IM Naloxone until respiratory increases ```

FYI | When more than CNS depressant drug is administered the doses of both drugs must be reduced

Hypersensitive state acquired through exposure to a particular antigen and then re-exposure to said antigen which produces a heightened reaction

allergy

FYI | A patient with multiple allergies is more likely to have an allergic response to drugs used in dentistry

What drug and through what route is most responsible for the majority of anaphylaxis

Penicillin, paternal

Risk of opioid allergy?

low

patients with a history of nasal polyps, pan sinusitis and asthma have a greater risk for what analgesic? How does it present

aspirin | bronchospasm

Local Anesthetics what type do you use with increased risk of allergy? What component of a cartridge is a bacteriostatic agent that causes a dermatologic response? What component of a cartridge is used as a vasoconstrictor preservative and causes respiratory reaction (higher in asthmatics)

Ester Methylparaben Sodium bisulfite

With an alleged allergy to local anesthetics, what drug should be used as a precautionary measure?

histamine blocker aka Benadryl with 1:100,000 epi

What is safe to use with ester allergy? What is safe to use with paragon allergy? What is safe to use with sulfite allergy? What is safe to use with an amide allergy?

amides No concern local anesthetics w/out vasoconstrictor general anesthesia in hospital

Immediate Allergies Onset- Type/s- -the more ___ the signs and symptoms, the more intense the ultimate reaction

- seconds to hours - I, II, III - rapid

Delayed Allergies Onset- Type/s- More or less intense than immediate?

- hours to days - IV - less

Type I Allergic Reaction Onset- General anaphylaxis includes which systems? -if hypotensive and unconscious termed _____ Localized anaphylaxis includes which systems?

-immediate all anaphylactic shock one organ system

Skin Reactions Most common- includes 2- Angioedema (definition)

uritcaria -pruritis (itching) -wheals localized swelling, skin color and temp normal, can lead to airway obstruction

Respiratory Reactions classic manifestation-

bronchospasm

Generalized anaphylaxis Reactions Type of reaction- Maximal intensity within ___ to ___ mins When do fatalities occur? Most likely to occur with _____ administration

-Acute life threatening -5 to 30mins first 30 mins -parenteral administration

System Progression of Generalized Anaphylaxis 4

Skin Eyes, Nose, GI Respiratory Cardio (Skins ENouGh Rest Car) yes it sucks but the letters match well

Management of Delayed Skin Reactions Define delayed skin reactions P CAB D (if localized reaction) -Drugs 2, Adult dose, child dose (4 total doses) - How many doses per day for how many days? (if generalized) days? -Drugs 3, Adult dose, child dose (4 total doses)

appear after 60mins or more and DO NOT PROGRESS ``` P- comfortably CAB- not needed D L- oral histamine - Chlorpheniramine A=4mg C=2mg - Diphenhydramine A=50mg C=25mg - 3-4 doses a day for 3 days ``` G- IM or IV histamine blocker, 3 - chlorpheniramine A=10mg C=5 - Diphenhydramine A=50mg C=25mg

Management of Rapid Onset Skin Reaction ``` Onset- P D -if absence of cardio/resp involvement - if presence of cardiac/resp involvement P a)administer b)Start ___ c) administer ____ d) administer ____ if ^ doesn't work EMS ```

before 60mins ``` P- comfortably D -administer histamine blocker IM or IV with oral prescription for three days P- move patient to supine position a) oxygen b) IV c) epinephrine d) histamine blocker IM ```

Management of Respiratory Reactions most likely situation in which an allergic reaction will manifest as bronchospasm, it manifests in vv asthmatic patient allergic to ____ other drug that commonly causes respiratory reactions?

bronchospasm bisulfites aspirin

Management of Respiratory Reactions Laryngeal Edema - common signs 2 - type of sound produced

- exaggerated chest movements - cyanosis -high pitched crowing

Management of Generalized Anaphylaxis fyi- cardio collapse may occur within mins of onset in the dental office three things iconically cause this, what are they? P D 2 ***anaphylaxis is only emergency where drug administration is a must after diagnosis for recovery.

1. parenteral penicillin 2. aspirin 3. latex P-supine D- .3mg inta lingual or sub lingual epi

True or False | Cardiovascular disease is present to some degree in all adults

True

The three most common causes of chest pain in a dental office

Angina Hyperventilation MI

Risk Factors for Heart Disease Nicotine - increases 2 - decreases 1

increases myocardial demand for 02 increases adhesiveness of platelets lowers threshold for ventricular fibrillation

Why does incidence of heart disease increase in women after menopause but not males?

estrogen may delay atherosclerosis progression

reactive biologic response of arteries to the forces being generated by the flow of blood

atherosclerosis

______ creates a hard lesion that begins to obstruct blood flow. This leads to three things ``` Of these three things, each lead to 2 more complications 1. a) b) 2. a) b) 3. a) b) ```

calcium 1. chronic ischemia a) heart failure b) dysrhythmia 2. acute ischemia a) angina b) TIA 3. infarction a) MI b) CVA

arteries on ___ of myocardium are affected by atherosclerosis. Most common site?

surface ant. descending branch of Left coronary A.

# define angina including where it is usually felt and a few things that can cause it what relieves it?

substernal exercise, emotion, heavy metal vasodilators

Stable (constant) Angina - result of - precipitated by - pain lasts __ mins - pain relieved with

- coronary artery disease - strenuous activity, emotion, exposure to cold and eating - 1-15mins - nitroglycerine

Variant Angina - occurs during - associated with - caused by - most common in women age - occurance - pain relieved with

- rest - dysrhythmia - coronary artery spasm - under age 50 - same time each day - nitroglycerine

Unstable angina - syndrome that lies intermediate between ___ and ___ - cause - pain last ___mins Three subsets I - angina occurrence II - angina occurrence III - angina occurence

- stabel angina and MI - increase atherosclerotic disease - 30min I- 1st time II- on exertion III- angina at rest for 15mins or longer

True or False Sharp pain is typical of angina

False

what is Levine sign?

patient place clenched hand to chest when describing episode

Chest pain less than ___ is not anginal but of non cardia origin

30 secs

On average, a stable angina patients has ___ episodes per week

1 or 2

Nitroglycerin and rest usually relieve stable discomfort in ____

2-4mins

If relief from angina is felt when leaning forward, what disease is the cause? If relief from angina is felt when holding breath and deep expirations, what disease is the cause?

acute pericarditis pleurisy

Nausea and vomiting with chest pain is a indication for- Chest pain with palpitations is an indication for- Chest pain with hemoptysis is an indication for- Chest pain with fever is an indication for-

MI tachdysrhythmia pulmonary embolus or tumor pneumonia or pericarditis

typical anginal patients represent an ASA of

III

Premedication with ___ 5 mins before appointment should be used with patients who have more than one episode a week who have dental anxiety

nitroglycerine

Administering Nitroglycerine where is it deposited? no more than ___ within a 15min period

sublingually 3

How does Nitroglycerine work? ``` ____return of venous blood to heart ____cardiac output ____cardiac workload ____oxygen requirement ____of oxygen insufficiency ```

produces a decease in systemic vascular resistance through arterial and venous dilation ``` decrease decrease decrease decrease reversal ```

True or False acute MI can occur in absence of coronary artery narrowing?

True

Signs and Symptoms of CHF 4

1. peripherial cyanosis 2. coolness of extremities 3. peripheral edema 4. orthopnea

Stress Reduction Protocol for CHF patients O2 administration flow rate and through what?

3 to 5 L/min through a nasal cannula

True or False Nitroglycerine will reduce the pain of an acute MI

false

Patient appearance during acute MI

ashen gray face, nail beds cyanotic

Acute MI - 93% ____ dysrhythmia are seen

PVCs

True or False Blood pressure may be normal during acute MI but is normally low

both statements are true

Management to Acute MI symptoms: pressure, tightness, epigastric pain, jaw pain that last longer than ____mins

30mins

Why should we administer 02 if we suspect an MI

decrease the size of the infarct

Why should we administer aspirin if we suspect an MI

fibrinolysis

True or False Nitroglycerine should be administered if MI is suspected.

False, during an MI BP is already LOW

Treatment for left ventricular failure with resultant pulmonary edema

bloodless phlebotomy

Thrombolytic therapy of greatest benefit in the first ___

1 to 3 hours

Biological death of neuronal tissue takes place in ___ if no oxygen is present

4-6mins

Chain of Survival for Cardiac Arrest 1st- 2nd- 3rd- 4th-

1- early access/recognition activate EMS 2. Early BLS 3. Early Defibrillation 4. Early ACLS (advanced cardia life support)

Two specific entities of cardiopulmonary arrest In most instances ___^ precedes ____ ^

respiratory arrest and cardiac arrest

any clinical situation in which the circulation of blood is absent or inadequate to maintain life

cardiac arrest

During cardia arrest describe PEA. | Should we defibrillate?

Pulseless Electrical Activity is normal but too week to cause contraction No

Should we Shock? ``` Cardiac Arrest? Pulseless VT? -what is it Pulseless VF? -what is it? Asystole? -what is it? ```

NO accelerated beating of ventricles, YES unsynchronized contraction of myocardium, YES absence of contractile movements, NO

what is the maximum time circulation should be assess during BLS

10 sec

Location of Pressure Point for BLS Adult Child Infant

Adult- middle of sternum between nipples Child- middle of sternum between nipples Infant- intermammary line

Hand Position BLS Adult Child Infant

Adult-heel of hand on pressure point Child- heel of hand on pressure point Infant- two or three fingers on pressure point

Compression during BLS Adult Child Infant

Adult- 2in Child- 2in Infant- 1.5in

Rate of compressions per min Adult Child Infant

ALL 100

How many ventilation breaths per ventilation ``` Adult -one rescuer -two rescuers Child -one rescuer -two rescuers Infant -one rescuer -two rescuers ```

``` Adult -30:2 -30:2 Child -30:2 -15:2 Infant 30:2 15:2 ```

Test 2 Flashcards

(139 cards)