DAANCE Office Anesthesia Emergencies 2 — Questions and Answers
Question 1: The initial management of a dental patient experiencing an acute asthmatic attack unresponsive to their own rescue inhaler is:
- Administer IV antihistamine (diphenhydramine) immediately
- Administer epinephrine 0.3 mg IM and activate EMS if severe (Correct answer)
- Place patient supine and apply high-flow oxygen via nasal cannula
- Administer IV ketamine for its bronchodilatory properties
Correct answer: Administer epinephrine 0.3 mg IM and activate EMS if severe
Severe bronchospasm unresponsive to beta-2 agonist inhaler requires epinephrine IM and EMS activation, as the patient may be progressing to status asthmaticus.
Epinephrine beta-2 effects provide potent bronchodilation, while alpha-1 effects help maintain blood pressure. Sitting the patient upright (not supine) reduces diaphragmatic restriction. High-flow O2 by mask is appropriate. EMS activation is mandatory for severe status asthmaticus not responding to initial therapy.
Question 2: Laryngospasm is BEST distinguished from bronchospasm during sedation by:
- Presence of expiratory wheezing on auscultation
- High-pitched inspiratory stridor and complete or partial upper airway closure (Correct answer)
- Hypotension and tachycardia as primary findings
- Gradual onset over 10 to 15 minutes
Correct answer: High-pitched inspiratory stridor and complete or partial upper airway closure
Laryngospasm typically presents with high-pitched inspiratory stridor (partial) or silent chest with no airflow (complete closure) - an upper airway finding, unlike the expiratory wheeze of bronchospasm.
Laryngospasm is reflex glottic closure triggered by secretions, blood, or airway stimulation. Complete laryngospasm produces a silent chest with paradoxical chest/abdominal movement. Partial laryngospasm produces inspiratory stridor. Treatment: positive pressure with 100 percent O2, jaw thrust, chin lift, and if persistent, small IV succinylcholine.
Question 3: During IV sedation, a patient develops lip swelling, urticaria, and wheezing 10 minutes after cefazolin administration. The FIRST drug to administer is:
- Diphenhydramine 50 mg IV
- Methylprednisolone 125 mg IV
- Epinephrine 0.3 mg IM (1:1000) (Correct answer)
- Albuterol inhaler 2 puffs
Correct answer: Epinephrine 0.3 mg IM (1:1000)
The clinical picture (urticaria plus angioedema plus bronchospasm after antibiotic) is anaphylaxis. Epinephrine IM is the FIRST and most critical intervention.
Every second of delay in epinephrine administration worsens outcomes in anaphylaxis. Antihistamines and steroids are slow-acting adjuncts that do NOT replace epinephrine. EMS should be activated. Following epinephrine: IV access, supine position (unless respiratory distress), IV fluid bolus for hypotension, diphenhydramine, and corticosteroids.
Question 4: A patient develops a vasovagal syncope episode during local anesthetic injection. The FIRST action is:
- Administer 0.5 mg atropine IV immediately
- Place the patient in Trendelenburg position (supine with legs elevated) (Correct answer)
- Inject epinephrine 0.3 mg IM
- Check blood glucose immediately
Correct answer: Place the patient in Trendelenburg position (supine with legs elevated)
Trendelenburg positioning restores cerebral perfusion by increasing venous return to the heart. This, combined with discontinuing the procedure, resolves most vasovagal episodes.
Vasovagal syncope results from excessive vagal tone causing bradycardia and vasodilation. Laying the patient flat or in Trendelenburg rapidly improves cerebral perfusion. Supplemental oxygen and ammonia inhalants are additional measures. Atropine is reserved for persistent symptomatic bradycardia not responding to positioning.
Question 5: A patient with known coronary artery disease develops chest tightness and diaphoresis during dental sedation. After positioning and administering supplemental oxygen, the NEXT priority is:
- Completing the dental procedure quickly to reduce procedure time
- Activating EMS and administering aspirin 325 mg chewable if not contraindicated (Correct answer)
- Administering IV midazolam to reduce patient anxiety and pain
- Rechecking blood pressure and waiting 15 minutes to reassess
Correct answer: Activating EMS and administering aspirin 325 mg chewable if not contraindicated
Suspected AMI requires immediate EMS activation, aspirin administration, and nitroglycerin if appropriate. Do not delay EMS to wait and see.
Classic AMI symptoms (chest tightness, diaphoresis, radiation to arm/jaw) in a known CAD patient demand immediate action: stop dental treatment, activate EMS, oxygen if SpO2 less than 94 percent, sublingual nitroglycerin if SBP greater than 90 mmHg and no PDE-5 inhibitor, and chewable aspirin 162 to 325 mg.
Question 6: Which maneuver is MOST effective for initial management of an obstructed airway in an unconscious patient with a foreign body above the glottis?
- Blind finger sweeps of the pharynx
- Abdominal thrusts (Heimlich maneuver) in supine position
- Head-tilt-chin-lift followed by direct visualization and manual removal if visible (Correct answer)
- Immediate cricothyroidotomy
Correct answer: Head-tilt-chin-lift followed by direct visualization and manual removal if visible
Head-tilt-chin-lift opens the airway, and if the foreign body is visible on direct inspection, manual removal is attempted. Blind finger sweeps may push the object deeper.
In an unconscious patient with suspected foreign body airway obstruction: open the airway, look for the object, and remove only if visible. Blind sweeps risk pushing the object into the larynx. Abdominal thrusts are used for complete obstruction in a conscious patient.
DAANCE Office Anesthesia Emergencies 2
The initial management of a dental patient experiencing an acute asthmatic attack unresponsive to their own rescue inhaler is: