10/15/10 IDHA Dental Office Medical Emergencies: More than CPR

10/15/10 Dental Office Medical Emergencies: More than CPR IDHA Program content and goals 
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Name 3 aspects of patient assessment must be completed prior to patient treatment Identify possible contraindications to oral health treatment Describe signs and symptoms of common emergency situations Management of overdose, allergic and psychogenic local anesthetic reactions Explain basic medico‐legal responsibilities Dental Office Medical Emergencies by Lexi‐comp www.lexi.com 10% Discount by mentioning this course #J3Y9U GoToDDS www.gotodds.com Use code POC for discount Preventing Medical Emergencies: Use of the Medical History Frieda Pickett, RDH, MS JoAnn Gurenlian, RDH, PhD www.lww.com left side of screen 15% discount Dental Office Medical Emergencies
1. The prognosis for treating medical emergencies is dependent on: a. Time of diagnosis b. Execution of appropriate treatment c. Ability to identify a problem d. All of the above 2. Asthma and allergy have the following in common: a. Hives b. Bronchospasm c. Drop in blood pressure d. They have nothing in common 3. The drug of choice in an anaphylactic reaction is a. Benadryl b. Diphenhydramine c. Epinephrine d. Tylenol Patti DiGangi, RDH,
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10/15/10 Dental Office Medical Emergencies: More than CPR IDHA 4. Epinephrine is the drug of choice in the treatment of anaphylaxis because it: a. Acts as bronchodilator b. Elevates blood pressure c. Lowers blood pressure d. Both a and b 5. A patient might describe an angina attack as feeling: a. Bloated b. Pins and needles c. Tightness or heaviness d. All of the above 6. After a myocardial infarction, the area of the heart distal to the blood clot takes approximately ___ hours to die a. 2 b. 4 c. 6 d. 8 7. How long after an MI should a patient postpone elective dental treatment? a. 3 months b. 6 months c. 1 year d. It is not necessary to delay treatment 8. Local anesthetic dosages should be altered for which of the following patients? a. Pediatric b. Geriatric c. Patients with liver disease d. All of the above 9. In the case of a mild local anesthetic overdose: a. Oxygen should be administered b. Symptoms may develop immediately after injection c. Patients become lethargic d. All of the above 10. Nitroglycerin should be administered to the angina patient every 5 minutes as needed until symptoms are relieved. a. True b. False Patti DiGangi, RDH,
BS
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10/15/10 Dental Office Medical Emergencies: More than CPR IDHA 11. The patient who loses consciousness should be placed in which position? a. Trendlenberg or supine b. Upright c. Prone d. Any of the above 12. Which of the following is not a symptom of a patient with declining blood sugars? a. Mental confusion b. Slurred speech c. Diaphoresis d. Palpitations 13. All of the following should be done when managing any seizing patient except: a. Placing the person in a supine position b. Inserting a padded tongue blade between the teeth c. Loosening clothing around the neck d. Administering oxygen 14. It is recommended that aromatic ammonia be within arm’s reach in every treatment room. a. True b. False 15. Oxygen must be available in a. “B” cylinder b. “D” cylinder c. “E” cylinder d. “F” cylinder Avoiding an Emergency‐The Basics Thorough written, signed, dated health profile  Established baseline vital signs  Recognition of an emergency  Proper content and knowledge emergency kit  Proper treatment room and office set up  Proper dental chair set for emergency Pray  Preparedness of dental office personnel to take on the role of first responder  Recognition of predisposing history/presenting signs and symptoms of an emergency  Action to stabilize, using basic life support techniques, and/or treat the patient  Yell for help by activating the Emergency Medical System (EMS) when necessary Patti DiGangi, RDH,
BS
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10/15/10 Dental Office Medical Emergencies: More than CPR IDHA Office BP Measurement 
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Use properly calibrated and validated instrument Patient seated quietly for 5 minutes, feet on the floor, and arm supported at heart level. Appropriate‐sized cuff should be used to ensure accuracy Metabolic syndrome Cluster of risk factors for cardiovascular disease and type 2 diabetes mellitus Occur together more often than by chance alone Affects about 47 million Fat is an inflammatory tissue 
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Releases TNFα, C‐reactive protein, and other cytokines Obesity Affects up to 30% of the US population The Three‐way Street According to Robert Genco, “Obesity can intensify infections, such as periodontal disease; cytokines produced by fat cells are known to trigger insulin resistance, which can lead to type 2 diabetes. Diabetes, in turn, is known to increase the risk for periodontal disease. New research suggests that periodontal disease can affect a diabetic patient’s ability to control blood sugar levels.” Emergency Readiness 
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Stethoscope Nasal cannula Magill forceps Yankauer suction tip Suction tip Tongue forceps Wrist and arm BP cuff AED Drug Kit Clipboard Pocket mask: Connects to O2 & ambu‐bag Oxygen tank: “E” cylinder, Enough for nonbreathing adult for ½ hr. Ambu‐bag Flashlight Scissors Contact with Hospital or ER Patti DiGangi, RDH,
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10/15/10 Dental Office Medical Emergencies: More than CPR 
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IDHA Call hospital prior to patient arrival to give patient status Give hospital your name and phone numbers Document phone call in patient chart If possible DDS should consider accompanying patient to hospital Documentation Post‐Incident 
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Document everything possible with emergency incident Times and progression especially important Document EMS time of arrival, treatment and time of departure Depending on seriousness of emergency, consider dismissing the rest of the patient’s for day to have staff meeting to discuss event Restore health not just teeth and gums  Dental hygienists are the professionals best suited to guarantee prevention because we are licensed and educated to provide safe, effective, quality care to all Americans. ‐ADHA Thank You: GC America www.gcamerica.com Young Dental www.youngdental.com Sunstar www.sunstaramericas.com CariFree System www.carifree.com Appendix A – Blood Pressure Guidelines Limits for Normal BP Children & Adolescents Age/sex
Systolic
Diastolic
1-4 female
97-106
53-65
1-4 male
94-109
50-65
5-12 female
103-120
65-77
5-12 male
104-121
65-78
13-17 female
118-126
76-81
13-1 male
117-134
75-85
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10/15/10 Dental Office Medical Emergencies: More than CPR IDHA Hypertensive Patient above age 18 BP Dental Considerations <140/90 Routine dental care can be provided
Remeasure BP at recall as screening strategy for hypertension 140‐
159/90‐99 Remeasure BP after 5 min. and patient has rested
Measure prior to any appt; if patient has measurements above normal at 2 separate appts. And has not been Dx. As hypertensive, referral Inform patient BP measurement Routine Tx. can be provided 160‐
179/100‐
109 Remeasure BP after 5 min. and patient has rested
If still evaluated, inform patient of readings Refer for medical eval. Within 1 month; delay Tx. if patient is unable to handle stress; or if dental procedure is stressful. Routine Tx. can be provided. Consider using stress reduction protocol during Tx >180/>110 Remeasure BP after 5 min. and patient has rested
Delay elective dental Tx. until BP is controlled, require a medical release form approving oral healthcare Tx. to be completed and signed by patient’s physician If emergency dental care is needed, it should be done in a setting in which emergency life support equipment is available Appendix B ‐ Specifics on Drug Kit Epinephrine 
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Single most important drug in kit Anaphylaxis is life threatening 1:1,000 ratio o Adult dose .3mg o Child dose .15mg  No medical contraindication in anaphylactic emergency Diphenhydramine (Benadyl)  Histamine blocker: Injectable or pills  Non‐life threatening allergic reactions  After epinephrine in anaphylactic reactions  No medical contraindication of histamine blocker during emergency Nitroglycerin 
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Vasodilator must be in emergency kit Patients with angina often bring own pill Patti DiGangi, RDH,
BS
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10/15/10 Dental Office Medical Emergencies: More than CPR IDHA 
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Recommend Nitrolingual Spray: Effective as pills, longer shelf life, one spray = 1 tablet 2 Contraindications o Patient suffering from chest pain with signs of drop in BP (e.g. feels faint or dizzy) o Chest pain but has taken Viagra in previous 24 hrs. (Viagra + Nitroglycerin can lead to unconsciousness) Bronchodilator  Used to Tx. acute asthma attack  Patients often bring own inhaler  If patient doesn’t  Office should have in emergency kit  Most common drug used in U.S. Albuerol  After inhaler, symptoms should subside in 30 sec. to 1 min. Glucose 
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Most common hyperglycemia (low blood sugar) InstaGlucose tube Orange juice, non‐diet soda Liquid better Aspirin 
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Part of pre‐hospital tx. for suspected heart attack victim One tablet (325 mg) chewed not swallowed 3 Contraindications o Allergic to aspirin o Bleeding disorder of any type o Gastric or peptic ulcer  There are NO substitutes for aspirin Secondary Drug: Aromatic Ammonia 
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Management someone who is or has fainted Noxious odor stimulates movement which increased blood flow to brain in supine position In addition to emergency kit, should have 2 taped to wall/cabinet within reach in every treatment room Patti DiGangi, RDH,
BS
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10/15/10 Dental Office Medical Emergencies: More than CPR IDHA Appendix C ‐ Dental Chair Recovery Positions Trendelenburg Position  Get blood flowing to brain  Support heart and kidneys  Used for: Fainting, Unconscious patient, Choking patient, Seizure episodes Supine Position  Used for CPR in chair as support for body  Used to treat anesthetic toxicities  Cardiac arrest  Angina episodes  Myocardial infarctions Upright Position 
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Uncontrolled bleeding Hypertensive attack Asthma attack Anaphylactic or any respiratory situations Stroke patient o If suspect stroke NEVER move head o Could dislodge blood clot o Create more lasting damage Patti DiGangi, RDH,
BS
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10/15/10 Dental Office Medical Emergencies: More than CPR IDHA Recovery Position 
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Position of patient after symptoms resolve While waiting for EMS Recovery position as learned in CPR classes: On their side, One knee bent
Appendix D - Handling Specific Situations
Syncope/Fainting  Physiology: Insufficient blood (O2) to brain  Signs: Pallor, perspiration, dizziness, nausea, pulse initially rapid the slow, low BP, loss of consciousness  Management: Trendelenburg position, Maintain open airway, O2, Loosen tight clothing, Monitor vital signs Orthostatic Hypotension 
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Physiology: Insufficient blood (O2) to brain upon arising from reclined position Signs: Low BP, loss of consciousness Management: Trendelenburg position, Maintain open airway, O2, Raise chair slowly for dismissal, Monitor vital signs Adrenal Crisis 
Physiology: Inability of adrenal gland to supply sufficient corticosteroid to maintain BP during stressful event resulting in loss of consciousness  Signs: Anxiety, weakness, fatigue, nausea, pain in abdomen, back, legs, loss of consciousness  Management: Trendelenburg position, Maintain open airway, O2, BLS, Monitor vital signs, Corticosteroid may be administered by DDS, Transport to hospital Hyperventilation 
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Physiology: Increased ventilations brought on by anxiety . . . Increase in blood O2 levels, decrease in CO2 Signs: Increased rate and/or depth of respirations, tingling/numbness in extremities, lightheadedness Management: Upright position, Calm patient, Slow rate of breathing by having patient mimic clinician’s slowed breathing Patti DiGangi, RDH,
BS
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10/15/10 Dental Office Medical Emergencies: More than CPR IDHA Categories & Features of Epilepsy Simple partial Tingling sensation in arm, finger, or foot
Perception of foul odor Seeing flashing lights Speaking unintelligently Remains conscious Complex partial Episode of ‘automatic behavior’
Sits motionless or moves in an inappropriate way Remains conscious Can progress to convulsive seizure, unconsciousness Generalized convulsive Stiffening, convulsions, thrashing movements
May cry out May lose urinary and bowel control May bite tongue Unconsciousness, falls to floor, unaware of seizure After seizure confused, desire to sleep Blank stare Generalized nonconvulsive/absence Rhythmic blinking of eyes Brief unconsciousness, unaware of seizure After seizure, acts as if nothing happened Seizure Episode 
Physiology: Abnormal brain activity causing disturbances in behavior, concentration, movement; cause may be hypoglycemia, drug overdose, hypoxia, epilepsy, fever  Signs: May range from mild twitching to grand mal seizures. Post seizure depression phase  Management: Supine position, Protect patient from injury, Move equipment, Padding under, Turn on side if possible to maintain airway, BLS, Physician consult to determine need for medical evaluation Asthma Attacks 
Physiology: Constriction of bronchi and increase in mucus into bronchi in response to irritant resulting in narrowed air passages  Signs: Thickness in chest, coughing, difficulty breathing, wheezing, anxiety, cyanosis, if severe  Management: Upright position with arms forward, Assist patient with brochodialator, O2,Monitor vital signs, Epinephrine if difficulty persists, Medical assistance if necessary Allergic Reactions: Urticaria or Pruritus 
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Physiology: Hypersensitivity to allergen resulting in skin reaction occurring hours after exposure Signs: Itching, swelling, rash on face, hands, feet Patti DiGangi, RDH,
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10/15/10 Dental Office Medical Emergencies: More than CPR IDHA 
Management: Upright or semi‐reclining position, Antihistamine IM or orally, Monitor progression of signs and symptoms Allergic Reactions: Respiratory Reaction  Physiology: Hypersensitivity to allergen resulting in narrowed air passages  Signs: Difficulty breathing, wheezing  Management: Upright position with arms forward, O2, Epinephrine inhaler or injection, BLS, Medical consult Allergic Reactions: Anaphylaxis 
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Physiology: Hypersensitivity occurring <60 minutes after exposure Signs: Skin reaction, difficulty breathing, wheezing, GI cramping, vomiting, cardiovascular collapse, shock Management: Manage signs and symptoms, Epinephrine, O2 and ventilate manually if necessary, Position for comfort‐often supine, Monitor vital signs, If unconscious, BLS, Transport to hospital Local Anesthetic Reactions Anesthetic Toxicity  Main cause of toxicity includes: liver diseases, too rapid intervascular injection, too large dosage, blood diseases  Minimize effects by monitoring dosage and use of vasoconstrictors  Beta blockers, thyroxine, and codeine cause an increase in local anes. in bloodstream  Seizures can result from overdose Local Anesthetic Reactions: Psychogenic Reactions 
Physiology, Signs, Management: Syncope, hyperventilation Local Anesthetic Reactions: Epinephrine 
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Physiology: Rapid elevation of BP sometimes related to interactions with other medications Management: Position for comfort, O2, Reassure patient, Monitor vital signs‐may take 20 minutes for BP to return to normal range, EMS if BP doesn‘t return to normal Local Anesthetic Reactions: Overdose/Intravascular injection 
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Physiology: Too much local anesthetic or epinephrine/injection into blood vessel Signs: Excitement of central nervous system followed by depression (rare in children and small adults,) apprehension, restlessness, tremors, rapid pulse, anxiety, confusion, rapid breathing; may lead to seizures Management: Mild Reaction: O2, Monitor vital signs Severe Reaction: Contact EMS, Supine position, Maintain open airway, Monitor vital signs, BLS. If trained and if patient in seizure: Anticonvulsant drug i.e. Valium and manage post lethargy state following seizure Diabetic Emergencies: Insulin Shock 
Physiology: Too much insulin in bloodstream following injection and insufficient food intake causing hypoglycemia Patti DiGangi, RDH,
BS
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10/15/10 Dental Office Medical Emergencies: More than CPR 
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IDHA Signs: Sudden onset, pale, moist skin, confusion, anxiety, tremors, convulsions, loss of consciousness Management: If conscious: Give sugar, juice, candy; Monitor vital signs, If losing or lost consciousness: BLS, Monitor vital signs, Administer Dextrose IV, if possible; Transport to hospital
Diabetic Emergencies: Diabetic Coma 
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Physiology: Excessive blood glucose levels . . Body produces insufficient insulin to metabolize blood sugar Signs: Gradual onset, dry, red skin, thirst, confusion, deep breathing, acetone breath, loss of consciousness Management: BLS, Monitor vital signs, Saline IV if possible, Transport to hospital Note: Sugar may be given to conscious patient if doubt exists whether condition is insulin shock or diabetic coma Angina 
Physiology: During stress or exercise, cardiac muscle requires additional oxygenated blood, blood vessels compromised by atherosclerosis unable to dilate or when blood is diverted to other areas of the body such as after eating a heavy meal  Signs: Cramping, suffocating pain or pressure in the chest area, numbness or tingling may radiate to shoulders, arms, jaws or throat  Management: Reposition to upright position, Measure BP, pulse, record values. If systolic BP is >100, place their nitroglycerin sublingually (if they don’t’ have their own with, use nitroglycerin spray from emergency kit 2 sprays in 2 minutes), Provide 100% oxygen, Re‐administer sublingual nitroglycerin as needed, maximum 3 tablets in 10 min., If not relieved in 10 minutes, call 911 Stroke/Cardiovascular Accident (CVA) 
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Physiology: Insufficient blood supply to brain due to blockage or hemorrhage of cerebral vessel Signs: Sudden numbness or weakness, especially on one side of the body; Confusion or trouble speaking or understanding speech; sudden trouble seeing in one or both eyes; difficulty with walking, dizziness or loss of balance, coordination; sudden, severe headache with no known cause Stroke: Specific Conditions 
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Transient Ischemic Attack (TIA): Upright or semi‐reclining, O2, Monitor vital signs, Refer immediately for evaluation but some patients with Hx may refuse CVA Conscious Patient: Semi‐reclining, Monitor vital signs, Seek medical assistance, O2 CVA Unconscious Patient: Supine position, Record vital signs, BLS, O2,Transfer to hospital via EMS Patti DiGangi, RDH,
BS
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10/15/10 Dental Office Medical Emergencies: More than CPR IDHA Congestive Heart Failure/Pulmonary Edema 
Physiology: Weakened heart is unable to pump blood effectively causing back‐up of blood and congestion in the lungs and edema of the extremities  Signs: Extreme difficulty breathing, Wheezing, Feeling of suffocation, Frothy sputum, Extreme anxiety, Increased BP and pulse  Management: Upright position, Oxygen, Calm patient, Monitor vital signs, Transport to hospital Myocardial Infarction (MI) 
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MI occurs with blood clot of coronary artery Muscle distal to clot no receives blood Heart muscle begins to die Takes 6 hrs. to die Then considered damaged triggering irregular heartbeat Signals of Shock: Restlessness or irritability, Altered level of consciousness, Nausea or vomiting, Rapid breathing and pulse, Pale or ashen, cool. Moist skin. Excessive thirst Care for Shock: 
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Make sure 911 called Monitor ABC’s Control external bleeding Keep person from getting chilled or overheated Evaluate legs 12 in. if head, neck or back injury not suspected (Trendelenburg) Comfort & reassure Do not give anything to eat or drink Signals of Incident Stress – You as victim: Confusion, Lower attention span, Poor concentration, Denial, Guilt, Depression, Anger, Change in interactions with others, Increased/decreased eating, Uncharacteristic, excessive humor or silence, Unusual behavior Patti DiGangi, RDH,
BS
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Food Allergies Can
© Getty Images
Are You Prepared?
Kill
by Patti DiGangi, RDH, BS
How could this be happening?
Every second felt like an hour. She was still coughing and
wheezing, and that was a good sign. If she stopped, it meant
her airway was completely closed. Even though she couldn’t
breathe, she still didn’t want me to call 911, but of course I did.
We were eating and talking one moment; she jumped up and
was gone the next. All of my training in CPR wouldn’t make
much difference if her airway closed completely. Hopefully the
epinephrine and Benadryl would help keep her airway partially
open until more help arrived. Did I start hyperventilating myself?
No, I knew what to do. I realize now that staying current in
my first aid training, not just the required CPR, could mean the
difference between life and death. I know after this experience
that I am going to do everything I can to help more people,
particularly oral health professionals, realize that this scenario
could happen to them.
This emergency happened to my sister and me. My sister
has life-threatening food allergies that have forced her to go to
the emergency room many times. Some people call her a picky
eater, but she isn’t. She simply must avoid certain foods. She
xx
December 2006 RDH
www.rdhmag.com
food allergies
has become so sensitive that
United States were previously
she reacts not only to food,
estimated at 2 percent of the
Aquafresh Toothpaste ...
but also to flour and many
population; more current esA representative from
hair, make-up, and other selftimates show the incidence
GlaxoSmithKline has provided
care products most of us use
closer to 4 to 6 percent. In
the following statement:
every day.
the past decade, studies inDo we know what is in
dicate that the prevalence of
“We were recently contacted by several
the products that we recompeanut allergy in children has
consumers requesting information about the
mend to patients every day?
doubled.
possibility of trace amounts of peanut oil in our
More patients need to know
A food allergy is an adverse
Aquafresh toothpaste products. It was our belief
and are asking (see sidebar.)
reaction
to a food or food comthat trace amounts of peanut oil could be present
Professionals assume products
ponent
involving
the immune
in certain flavor blends purchased by Aquafresh
are safe for everyone because
system.
Toxic
reactions
are not
from external flavor suppliers. Consequently, we
they are not aware of any
related
to
individual
sensitivresponded to those consumers that there was a
problems occurring in the past.
ity, but occur in anyone who
possibility that trace amounts of peanut oil may be
But what if they’re wrong? In
ingests a sufficient quantity of
present in some Aquafresh products.
the case of my sister and many
trigger food. There are adverse
“Subsequently, we have contacted our flavor
others, serious injury and
reactions to food that involve
suppliers to confirm this information. We are pleased
death could occur because of
the body’s metabolism but not
to learn that all of the flavor blends currently used
our incorrect assumptions.
the immune system. These are
to manufacture Aquafresh toothpaste contain no
The American Academy
considered food intolerances.
peanuts, no peanut oil, and no peanut derivatives.
of Allergy, Asthma, and
Table 1 shows some conditions
“Until we were able to validate our flavor
Immunology (www.aaaai.org,
related to food intolerances.
blend
information, we chose to err on the side of
Milwaukee, Wis.) states there
True allergic reactions to
caution and told consumers that the products may
are approximately 50 milfood are either IgE-mediated
contain trace amounts of peanut oil. In light of
lion Americans suffering from
or nonIgE-mediated. As with
how serious some allergies can be, we felt that was
some form of allergy, and
most allergies, IgE-mediated
the right thing to do. As an additional assurance,
those numbers are growing.
antibodies are produced with
we are arranging to have independent tests of our
The immune system serves as
exposure to a food protein
toothpaste conducted.
our defense against countbinding with mast cells and
less substances in the air we
other cells in body tissue and
“We apologize if this has caused any confusion
breathe, things we touch, and
to basophils circulating in
or concern among our loyal customers. If consumers
food we eat. The term allerthe blood stream. Though
have additional questions, they may contact us toll
the reactions are the same,
gen refers to any substance
free at (800) 897-5623.”
that can trigger an allergic rethe pathogenesis of nonIgEmediated reactions is not clear,
sponse. When allergens enter
but we do know that T-cells and
the body of a person predisposed
macrophages play a role.
to allergies, a series of reactions occur and allergy-specific antibody immunoglobulin E (IgE) is produced. IgE antibodies travel
Many people are confused about food allergies, and myths
to the plentiful mast cells of the eyes, nose, lungs, and gastroabound. Some common myths include:
intestinal tract. The IgE antibodies attach to the mast cells and
• Food allergy is a myth. This is fiction. Food allergy is a wellunderstood medical problem that causes a clearly defined set
wait for their “radar” to detect their specific type of allergen.
The next time the person is exposed to the allergens to which
of symptoms.
they are sensitive, the allergens are captured by the IgE, and
• Food allergy is hard to diagnose because you never know
when you are going to react to food. This is fiction because in a
mast cells release chemical mediators such as histamine. The
mediators produce the symptoms and continue to recruit other
true allergy, the allergic person will react every time.
inflammatory cells, resulting in more inflammation. Though it is
• People with food allergy are allergic to so many foods that
they couldn’t eat if they avoided all of them. Studies have shown
not fully understood, substances that trigger allergic reactions
in some people have no affect on others. Family history seems
that a vast majority of people with food allergy are allergic to
to be the single most important predisposing factor. Yet many
one or two foods.
• Food allergy is diagnosed by food allergy testing. This is
suffering from allergies have no known family history.
Food allergies can be pervasive and potentially life-threattrue and false. Most of the time it is diagnosed by medical hisening. Our understanding of food-induced allergic reactions
tory. Food allergy blood tests can be helpful but may give a false
has increased dramatically in recent years. Food allergies in the
positive. The double-blind controlled food challenge remains
xx
December 2006 RDH
www.rdhmag.com
food allergies
Table 1
Conditions Related to Food
Intolerance: Non-immunologic
Adverse Reactions to Food
• Gastrointestinal disorders
• Structural abnormalities: hiatal hernia, pyloric stenosis,
Hirschprung’s disease, tracheoesophageal fistula
• Disaccharidase deficiencies: lactase, sucrase-isomaltase
complex, glucose-galactose complex
• Pancreatic insufficiency, cystic fibrosis
• Gallbladder disease
• Peptic ulcer disease
• Malignancy
• Metabolic disorders
• Galactosemia
• Phenylketonuria
• Pharmacologic-related conditions
• Jitteriness (caffeine)
• Pruritis (histamine)
• Headache (tyramine)
• Disorientation (alcohol)
• Psychological disorders
• Neurologic disorders
• Gustatory rhinitis
• Auriculotemporal syndrome (facial flush from tart food)
Manifestations of Food Allergy: Evaluation and Management.
American Family Physician Jan, 15, 1999 www.aafp.org/afp/
990115ap/415.html.
the gold standard for diagnosis of food allergies.
• Food allergy can be treated by desensitization shots or
drops. This is unfortunately not the case. The only treatment is
to completely avoid the problem food.
• Food allergy is rarely life-threatening. False. Food allergy
remains a major cause of anaphylaxis treated in emergency
rooms.
Though there are a number of promising therapeutic modalities being researched, the only proven therapy for food allergies is avoidance. This includes reading labels, avoiding high-risk
situations such as buffets, and asking about ingredients. Some
people think that picking an offending item out of a dish makes
a food safe. This is incorrect. For someone like my sister, removing a crouton from a salad still puts her at high risk for a reaction. Reactions can occur from aerosolized food protein in the
steam of cooking the food, particularly boiling seafood.
Not all reactions to food are a direct allergy to that food. An
oral allergy syndrome may bring on sensitivity to foods in the
same classification, in a cross-reaction manner. This can
occur in a person with no known food allergies. A person
with a ragweed allergy might react to fresh melons and
bananas. People with grass pollen allergy might develop
symptoms after eating raw tomatoes. A person allergic
to birch pollen might react after eating raw potatoes, carrots, celery, apples, pears, hazelnuts, or kiwi.
The Food Allergen Labeling and Consumer Protection
Act (FALCPA) became effective in January 2006. It ensures
that people can easily and accurately identify ingredients
that may cause a reaction. Under this law, allergen declarations must be in plain English. Though more than 160
foods have been identified as triggering food allergies,
this law is limited to the eight major food allergens which
account for 90 percent of food allergies in the United
States. These are milk, eggs, fish (e.g., bass, flounder,
cod), crustacean shellfish (e.g., crab, lobster, shrimp), tree
nuts (e.g., almonds, pecans, walnuts), wheat, peanuts,
soybeans, or any ingredient that contains a protein derived from one of these foods.
While some allergic reactions to food are mild, foodallergic individuals can experience severe reactions.
Generalized anaphylaxis caused by food allergies accounts
for at least one-third to one-half of the anaphylaxis cases
seen in hospital emergency departments. Anaphylaxis is
the dramatic multi-organ reaction associated with IgEmediated hypersensitivity. Fatal food-related anaphylaxis
appears to be more common in patients with underlying asthma. Symptoms usually appear rapidly, sometimes
within minutes of exposure. Immediate medical attention
is necessary.
Epinephrine has long been the treatment of choice
for acute anaphylaxis. Even when epinephrine is used
promptly, it is not always effective in severe cases. People
with diagnosed food allergies should have epinephrine
prescribed and carry it with them at all times. They should
also wear an identification bracelet describing the allergy.
Oral health professionals need to be aware of the location and
use of the patient’s epinephrine, and that it must be given intermuscularly, not intravenously or subcutaneously.
The American Academy of Allergy, Asthma, and Immunology’s
The Use of Epinephrine advocacy statement says: “Epinephrine
must also be available in many first aid situations for use by
trained personnel who can evaluate the scene, the indication,
benefit, and risk of treatment with epinephrine in individual
cases. These efforts could significantly reduce the annual death
rate associated with sting and food anaphylaxis.”
This statement emphasized the need for personnel trained in
first aid. Most practice acts require hygienists to maintain current CPR certification. CPR certification courses are not the same
as and do not always include first aid training. In November
2005, the American Heart Association (AHA) and the American
Red Cross (ARC) came together to review the scientific literature
and publish the 2005 Guidelines for First Aid, which updated
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food allergies
Anaphylaxis = Killer Allergy*
Who is at risk?
Anyone, especially those allergic to foods such
as peanut, tree nut, seafood, fin fish, milk, egg, and
wheat, or to insect stings or bites, natural rubber latex,
or medications.
When can it happen?
Within minutes, anytime the allergic person comes
in contact with his or her trigger.
How do we know?
Several symptoms occur at the same tie, such as
itching, hives, flushing, difficulty breathing, vomiting,
diarrhea, dizziness, confusion, and shock.
Where can it happen?
Anywhere — home, restaurant, school, child care,
sports facility, summer camp, car, bus, airplane, or
dental office.
What should we do?
Inject epinephrine, call 911 or your local emergency
number, and notify the individual’s family — in that
order. Act quickly. Anaphylaxis can be mild or fatal.
*Adapted from Simmons FER, Anaphylaxis, killer
allergy: long-term management in the community.
Journal of Allergy and Clinical Immunology 2006; 117:
367-377.
the previous guidelines. (Note: These first aid guidelines are in
addition to the 2005 AHA guidelines for CPR.) Topics that are
new to the 2005 guidelines include use of oxygen, use of inhalers, use of epinephrine auto-injectors, wounds and abrasions,
dental injuries, snakebites, and cold emergencies. These were
added to the coursework on seizures, bleeding, burns, musculoskeletal trauma, and poisoning.
An Internet search on dentistry and allergy lists numerous hits
on latex sensitivity and reactions to dental anesthetics. Though
latex and anesthetic sensitivity are important, they are not the
only situations in which an allergic reaction can occur. Could
a food allergic reaction or anaphylaxis occur in the dental office? Possibly, because dental health professionals often do not
know what the products they use contain. Even trace amounts
of seemingly innocuous ingredients could put someone at risk.
Unless we have a full understanding of the life-threatening pos-
sibilities of allergy, early symptoms might not be recognized.
Every dental health professional should enroll in a first aid training course, as well as maintain CPR certification.
It is my hope that with the research on promising therapeutic
modalities, improved product labeling, and training in first aid
along with a heightened awareness, my sister and others can
rest better knowing that help will be there when they need it,
particularly from their oral health providers.
Epilogue: It took several hours and multiple medications at
the hospital to stabilize my sister. It took another several months
to get her system back on track. Unfortunately, she has had
more reactions that have sent her the hospital. She has committed to a campaign to increase public and professional awareness. RDH
Author’s note: Thank you to Dr. Greg Sharon for his assistance
on this article. Greg Sharon, MD, is chairman of the Department
of Medicine and Medical Education at Glen Oaks Hospital in
Glendale Heights, Ill. He has practiced allergy/immunology in
both multi-specialty and single-specialty practices. He is involved
in drug allergy, asthma treatment, and psychoneuroimmunobiology, and has worked with Lyme disease, chronic fatigue, fibromyalgia, and addictive medicine patients.
References
1
Advocacy statement — the use of epinephrine in the treatment
of anaphylaxis. American Academy of Allergy, Asthma, and
Immunology. November 2002 www.aaaai.org/media/resources/
academy_statements/advocacy_statements/ps26.asp.
2
American Heart Association and American Red Cross release
joint Guidelines on First Aid. American Heart Association.
November 2005
http://camclstc.org/lstc/instructor/pdf/
instructor/TNUpdate2005GL1.pdf#search=%22American%20
Heart%20Association%20and%20American%20Red%20Cros
s%20release%20joint%20Guidelines%20on%20First%20Aid
%22.
3
Food allergies and asthma. International Food Information
Counsel. May 2004 http://ific.org/food/allergy/index.cfm.
4
Guidelines for first aid. American Red Cross/American Heart
Association. November 2005 https://www.instructorscorner.
org/ViewDocument.aspx?DocumentId=2271.
5
Hahn M, McKnight M. Answers to frequently asked questions
about FALCPA. The Food Allergy and Anaphylaxis Network. 2004
http://www.foodallergy.org/Advocacy/FALCPAFaQ14.html.
6
Sampson H. Update on food allergy. J Allergy Clin Immunol
May 2004; 113(5):805-19; quiz 820.
7
Sicherer S. Manifestations of food allergy: evaluation and
management. American Family Physician. Jan. 15, 1999. http://
www.aafp.org/afp/990115ap/415.html.
8
The connection between food allergies and asthma. The
Cleveland Clinic. January 2005 www.clevelandclinic.org/health/
health-info/docs/2200/2209.asp?index=8956.
9
Tips to remember: what is an allergic reaction? American
Academy of Allergy, Asthma, and Immunology 2006 http://
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food allergies
www.aaaai.org/patients/publicedmat/tips/foodallergy.stm.
10
Trends in allergic disease. American Academy of Allergy,
Asthma, and Immunology. 2006 www.aaaai.org/media/
resources/media_kit/trends_in_allergic_disease.stm.
11
Wasserman R. Food allergy: separating the fact from the
fiction. American Academy of Allergy, Asthma, and Immunology.
Winter 2005. www.aaaai.org/patients/advocate/2005/winter/
foodallergy.stm.
Patti DiGangi, RDH, BS, is a speaker, author, practicing dental
hygiene clinician, and American Red Cross authorized provider
of CPR and first aid training. She can be contacted through her
Web site at www.pdigangi.com.
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