Emergency in Dentistry

8/3/2019 Emergency in Dentistry

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Emergency in

DentistryIyad Abou-Rabii

DDS. OMFS. MSc. PhD


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Agenda slide

1. Introduction2. Medical emergencies that may be encountered in dental

practice3. Local anesthesia emergencies 4. Conclusion5. Q&A


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Dentist's duty

Dentists have an ethical and professional duty to be cognizant

of appropriate guidelines for the management of acute medical

problems that might occurthey also need to have the skills

and resources to follow this guidance.


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Clinical risk

managementClinical risk management is a systematic process for the identification, analysis,and control of adverse events or potential risks. Clinicians should always:take a full documented medical history;be aware of possible adverse reactions (if unsure seek expert advice);know the principles in the prevention and management of medical emergencies;regularly rehearse and develop the management of emergencies with the dentalteam and record all training sessions;ensure that regular checks are carried out on emergency equipment and theexpiry dates of emergency drugs; these checks should be recorded.


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Medical emergencies

in dentistry Life-threatening emergencies are rare but can occur at

any time in dental practice. Dentists must be able to provide acutely ill patients with

life-saving measures prior to the arrival of specialisthelp.

It is essential, therefore, that they are trained in themanagement of medical emergencies that they mightprecipitate or encounter.


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The prevention of

medical emergenciesA detailed medical history is of paramount importance.When assessing the significance of a patient's medicalproblems, it is helpful to consider the following questions. What are the effects, if any, of the medical condition(s)

on the proposed treatment? What effect will the proposed treatment have on the

disease? Are adverse drug reactions or interactions anticipated?


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Pain and anxiety

control

Methods of pain and anxiety control are of paramount importance in themanagement of medically compromised patients


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Be an oral physician

An awareness of potential problems or complicationsassociated with medical conditions can sometimes prevent a criticalincident. For example, hypoglycaemia is an acute complication of bothtype 1 and 2 diabetes mellitus. The timing of dental appointmentsshould be discussed with the patient so that they are compatible withthe patient's diabetic management, allowing adherence to usual eatingschedules.


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Medical emergencies that may beencountered in dental practice and thatrequire prompt management

Vasovagal attack Seizures Angina Asthma attack Hypoglycaemia Myocardial infarction Anaphylaxis Cardiac arrest


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Faint


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Faint

Causes Transient hypotension and cerebral ischaemia Predisposing factors include hypoglycaemia,

anxiety, fear, pain, and fatigue


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Faint

Signs Weakness, dizziness, pallor, sweating,

nausea, confusion, tachycardia followed by a

bradycardia, loss of consciousness. Minor convulsions or incontinence can occur.


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FaintManagement Place patient in a supine position with the legs elevated above the level of the

heart to improve cerebral flowA patient who is sitting may lower their head by placing it between their knees, this

is not as effective as lying a patient down.Lay a pregnant patient on her side. Administer oxygen. Reassure the recovering patient, a glucose-rich drink may be helpful. When a member of the dental team recognizes that a patient is likely to faint the

patient should be placed in a supine positionthis may prevent loss ofconsciousness.

If the patient fails to regain consciousness promptly other causes of loss ofconsciousness must be considered.


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Epileptic seizure


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Epileptic seizure

Causes Known epileptic Poorly controlled or non-compliance with drug

regimeStress, Hypoglycaemia; May accompany a faint. Overdose of local anaesthetic may cause seizures.


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Epileptic seizure

Signs Loss of consciousness Muscle rigidity followed by jerking

movements; incontinence may occur. Confusion may be present during recovery


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Epileptic seizure

Management Protect from injury Administer oxygen and maintain airway if possible. If the patient can be discharged home, ensure that they are

accompanied Status epilepticus is probable if seizure continues in excess of 7

minutes; therefore emergency services should be called. If status epilepticus is diagnosed diazepam (up to 10 mg) by

slow IV injection may be given; it is not always efficacious


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Asthma


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Asthma

Causes Pre-existing disease that is poorly controlled,

anxiety, infection, exercise, exposure to an

antigen


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Asthma

Signs Breathlessness with wheezing on expiration. If untreated, breathing may become

increasingly difficult


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Asthma

Management Salbutamol inhaler or nebulizer and oxygen. Place the patient in a comfortable position. If there is no improvement summon emergency

servicesHydrocortisone IV or IM may be given Status asthmaticus is a life-threatening condition


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Chest pain


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Chest pain

Causes Angina, myocardial infarction


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Chest pain

Signs Usually a crushing retrosternal pain, irregular

pulse, may experience breathlessness,

nausea, or vomiting


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Chest pain

Management Sublingual GTN, oxygen, Place patient in a comfortable position consult with the patient. Call emergency services if pain does not subside in 3 minutes Possible administration of oral aspirin (300 mg) if MI suspected; nitrous oxide

and oxygen, if available, can be helpful to reduce pain and anxiety. Monitor. If loss of consciousness follow the protocol for cardiopulmonary resuscitation.


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Hyperventilation


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Hyperventilation

Causes Stress, pain, or expectation of pain. This is often a response to unfocused fears. Can be associated with chronic generalized

anxiety disorder


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Hyperventilation

Signs Rapid breathing, tachycardia, trembling,

dizzy, faint, sweating Paraesthesia, muscle pain/stiffnessCan lead

to tetany. Patients can complain of chest pain


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Hyperventilation

Management Reassure Ensure comfortable position Stop treatment

Rebreathe expired air


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Cerebrovascular

accident


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Cerebrovascular

accident

Causes Ischaemia, haemorrhage, or embolism in a

cerebral artery.


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Cerebrovascular

accident

Signs A stroke (partial or total weakness on one side

of the body), dysarthria, aphasia, hemiplegia,

and possible loss of consciousness


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Cerebrovascular

accidentManagement Lay flat and administer oxygen, maintain airway, monitor

Summon expert help.


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Hematoma (causes)

The needle can nick vessels as it passes through highly vascular tissues.A nicked artery will usually result in a rapid hematoma, while a nicked veinmay or may not result in a hematoma.

Hematomas most often occur during a posterior superior alveolar or

inferior alveolar nerve blocks. The most common cause of needle breakage is sudden unexpected

movement of the patient. Some practitioners habitually bend the needle and the metal is weakened

in this area.


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Use a short needle for the PSA and be conscious of depth of penetrationfor these injections.

If the hematoma develops during an inferior alveolar nerve block, applypressure to the medial aspect of the mandibular ramus, Themanifestations will usually be intraoral.

Hematoma (prevention

and management)


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If the hematoma develops during an infraorbital nerve block, apply

pressure to the skin directly over the infraorbital foramen. Thediscoloration will be below the lower eyelid. If the hematoma develops during a mental or incisive nerve block apply

pressure over the mental foramen. The skin will discolor over the mentalforamen and swelling will occur in the mucobuccal fold.


and management)


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and management) If the hematoma occurs during a posterior superior alveolar nerve

block, the blood will diffuse into the infratemporal fossa, and swelling willappear on the side of the face just after the injection is completed. The

swelling occurs after a significant amount of blood has diffused, so directpressure is often useless. Apply external ice.

The hematoma will disperse within 7 to 14 days with or without treatment.Avoid dental therapy in the area until the tissue is healed.


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Broken needle (causes)

The most common cause of needle breakage is sudden unexpectedmovement of the patient.

Smaller gauge needles (size 30) are more likely to break than larger ones(size 25).

Some practitioners habitually bend the needle and the metal is weakenedin this area.


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Broken needle prevention

The best way to avoid needle breakage is to routinely use a 25-gaugeneedle for any injection where there is a significant penetration of tissue.

The hub is the weakest part of a needle, so unless the injection techniquespecifically requires it, the needle should not be inserted all the way to the

hub. A longer needle should be used.


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Broken needle management

When a needle breaks, remain calm. Instruct the patient to keep their mouth open, and if at all possible, place a

biteblock. If an end of the needle is visible, retrieve it with a hemostat orcotton pliers.

If it is not visible, do not try to retrieve it at this time. Explain to the patient

what has happened. Make a note in the patient's chart about the incident. Send the patient to an oral surgeon for consultation. They may surgically remove the fragment or if the procedure will cause

too much damage they may leave it where it is.


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Emergency equipment

required in the dental surgery* Pocket mask Self-inflating bag, valve, and mask with reservoir Oropharyngeal airways Nasopharyngeal airways Oxygen therapy masks Tubing and appropriate connectors to attach oxygen cylinders to oxygen masks Syringes and needles to deliver drugs by a parenteral route in an emergency IV cannulae and adhesive tape Independently powered portable suction apparatus with wide-bore aspiration tips. Blood pressure monitor


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Assessment and management of the collapsed adult patient.


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Q &A


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Thank

you.


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Emergency in Dentistry