Medical Emeregency

April 7, 2023 1

MEDICAL EMERGENCYIN THE DENTAL OFFICE

Angkatan XPembimbing : drg. Aries M., sp.BM

April 7, 2023 2

Emergency : a situation and condition that threatening/endanger life

Dental emergency : a life threatening situation that frequently occuring in dental office

“Dental conditions are not usually dangerous to life, but they are often exceedingly painful”

J.N.W. McCagie, Oral Surgeon

April 7, 2023 3

TOPICS

• Introduction– Basic principles emergency management

• Emergencies status– Pre op emergency– Durante op emergency– Post op emergency

• Drugs related

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• Morbidity accident in dental practice(1985-2000=30.608 px)– Syncope 15,4%– Allergic rx. 2,6%– Angina 2,5%– Hypotension 2,4%– Seizures 1,5%– Asthma 1,3%– Anaphilactic 0,3%– DM &overdose LA 0,2%– Heart failure 0,1%

INTRODUCTION

Stanley malamed, 2000

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• Emergency complication in dental practice :– During tx 129 case– Before & after tx 45 case

• Occurance of systemic complication :– During/after LA 55%– During tx 22%– After tx 15%– After leaving dental office 5,5%

INTRODUCTION


April 7, 2023 6

• Treatment perform complication in dental practice (dental surgery) :– Extraction 39%– Unknown causes 12%– Incision 1,7%– Apico/root surgery 0,7%

INTRODUCTION


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INTRODUCTION

Basic Principles of Medical Emergency ManagementPrevention is the most important phase of treating, include :1. Medical history2. Px evaluation :a. visual inspection

b. vital sign c. medical treatment

3. Treatment management

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• Prevention– Do physical examination– Medical history anamnesis– Vital sign : BP, HR, RR, T– Prophylactic?– Pain control– Duration of action– Post op monitoring

INTRODUCTION

April 7, 2023 9

PREVENTION


a. sphymomanometer

b. Mercury gravity manometer

c. Correct ear loop direction stetoscope

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PREVENTION

a. Proper placement of BP cuff

Important things:A. Px’s arm rest at level

of the heartB. Lower cuff +-1inch

from antecubital fossa

C. A.BrachialisD. HR? beat/min.E. Rhythm?re/irre?F. Slow release 2-3

mmHg/s.G. 1st sound=systole


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PREVENTIONblood pressure guidelines (ASA 2002) and dental therapy considerations

Blood pressure in adults, based on ASA 2002

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· <140/<90check annually

· 140-160/90-100recheck at 3 visits if no change medical consult concurrent with dental treatment.

· 160-200/100-115recheck in 5 minutes, no dental treatment and medical consult.

· >200/>115recheck in 5 minutes, no dental treatment and medical consult.

Lapointe, 2006

PREVENTIONblood pressure guidelines (ASA 2002) and dental therapy considerations

13

Situation Agent Dose regiment

General prophylaxis Amoxicillin -Adult:2 g, Children:50 mg/kg orally 1h before tx.

Inability oral medication Ampicillin -Adult:2 g IM/IV, Children:50 mg/kg IM/IV 30min before tx.

Penicillin allergy Clindamycin/

cefadroxil*/

azithromycin/ clarithromycin

-Adult:600 mg, Children:20 mg/kg oral 1h before tx.-Same as amoxicillin tx.

-Adults:500 mg, Children:15 mg/kg oral 1h before tx.

Penicillin alergy and inability take oral

Clindamycin/

cefazolin*

-Adult:600 mg, Children:20 mg/kg IV 1h before tx.-Adult:1 g, Children:25 mg/kg IM/IV 30min before tx.

Prophylaxtic agents

* Cepalosporins shouldn’t prescribe for immediate hypersensitivity reactions(urticaria, anaphylaxis)to penicillin s

April 7, 2023

Based on ASA 2002, general prophylactic agents., S.V.Mahadevan, 2005.

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Basic life support(cardiopulmonary resuscitation)

Look and see

• unresponse

Do what should to be

• Open airways

1st step

• 30 chest compressions

Next step

• 2 rescue breaths 30 compressions

Lapointe, 2006

April 7, 2023 15

ASA level statusLevel Status

I Normal, healthy without systemic disease

II Px with systemic disease

III Severe systemic disease, limits activity but not incapacitating

IV Incapacitating systemic disease that constant threat of life

V Not expected to survive 24 h with/out an operation


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ASA level & disease exampleLevel Example condition

ASA I Green light, able to flight, no risk

ASA II Yellow light, well controled NIDDM, epileptic, asthma, hyper/hypotiroidsm, pregnancy, allergic, >60 years old, adults BP 90-94/140-159 mmHg

ASA III Stable angina, 6months post myocardiac infark, well controled IDDM, COPD, CHF, adults BP >95/160mmHg

ASA IV Unstable angina, MI/CVA within 6months, BP >115/200mmHg, uncontroled IDDM&epilepttic, severe COPD

ASA V End stage cancer, renal disease, cardiovasc, hepatic disease


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GCS indexEye opening Motoric response Verbal response

Spontaneously 4 Obey 6 Oriented 5

To speech 3 Localizes pain 5 Confused 4

To pain 2 Withdraws from pain 4 Inappropriate 3Kata2 tidak tepat

None 1 Flexion to pain 3 Incomprehensible 2Tidak jelas

Extension to pain 2

None 1

None 1

s.v.mahadevan., 2005

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• General treatment principles

* it is imperative to address life threats first to treat emergency patient.s.v.mahadevan., 2005

BASIC PRINCIPLE OF MEDICAL EMERGENCY MANAGEMENT

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Airway management• Timely effective airway management can mean the difference

between life and death,


April 7, 2023 20s.v.mahadevan., 2005

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1. Medical history– S : symptoms– A : allergy– M : medical status– P : previous history– L : last incident– E : event leading problems

Lapointe, 2006

April 7, 2023 22

Medical historyBased on American Dental Association, stanley malamed., 2000

April 7, 2023 23Based on American Dental Association, stanley malamed., 2000

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2. Px evaluationa. Visual inspection of the px.b. Record vital signs.c. Complete medical treatment.


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Visual inspection in life threatening status1. BLS: remember ABC’s2. Place the patient supine.3. Maintain airway (o2 if needed).4. Monitor vital signs.5. Initiate specific treatment6. prepare for assisted.7. Prepare informed concent !

Lapointe, 2006


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2a.Visual Inspection ( emergency / usual treat? )should examine head to toe over px.


A B

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Which One Who’s Need To Treat 1ST?

A B

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TRAFFIC INCIDENTS, NEEDS RAPID TREATMENT

(emergency status)

B

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2b. Vital Sign



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GCS• Mild : 14-15• moderate : 9-13• severe : 3-8

GCS = E+M+V

Adapted from Teasdale G and Jennett B.9


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2c. Medical treatment examination– Cito?– Elective surgery?– Medication?– Consult?


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EMERGENCY STATUS(SYNCOPE)

What is the most common problems that we could face as a dentist practicioner?

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EMERGENCY STATUSSYNCOPE

• Three phase– Pre syncope : warm feelings, lightheaded, dizzy,

midriasis, increasing HR, sweating.– Syncope : brachycardia, loss of consciousness,

seizures.– Post syncope : variable to mental confusion,

blood pressure back to normal.

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SYNCOPE-UNCONSCIOUSNESS

• SyncopeStridor, wheeze,

respiratory distress orclinical signs of shock #2

For hypotension, lie patient flatwith legs raised

(unless respiratory distress increased)

Adrenaline #31:1000 solution

0.5 mL (500 micrograms) IM #4

Repeat 5 minutes for resurection if no response

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1. Stop all dental treatment.2. ABC’s, ensure that the airway is open.

(Remove all objects form the patient’s mouth).3. Place patient in supine position with legs and

arms elevated and head at level of heart (If patient is pregnant roll onto left side).

4. Use Ammonia ampule to stimulate breathing.

MANAGEMENT OF SYNCOPE/UNCONSCIOUSNESS

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5. Oxygen 3-5L/min by nasal canula or 10L/min by mask.

6. Reassess airway.7. If unconscious for more than 1 minute

activate EMS.8. Start IV if available.9. Augment ventilation if respiratory effort is

poor (Use Ambu bag.)10. Reassess airway every 30 seconds.


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• Differential diagnosis :– Stress– Postural hypotension

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EMERGENCY STATUSALLERGIC REACTION &DRUGS INDUCED

Often due to anaphilactic shock, over treatment, dosage passage (local anaesthethic), antibiotics?

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Signs and Symptoms:1. Cutaneous reactions are the most common occurrence

and include urticarial.2. Angioedema (Swelling) this varies from localized slight

swelling of the lips, eyelids, and face to more uncomfortable swelling of the mouth, throat, and extremities.

3. Respiratory (Tightness in chest, sneezing, bronchospasm).

4. Ocular reactions include conjunctivitis and watering of eyes.

5. Hypotension.

ALLERGIC REACTION

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CLINICAL EXAMPLES ALLERGIC DISEASE

• Anaphilaxis (drugs, venom inject)• Atopic bronchial asthma• Allergic rhinitis• Urticaria• Allergic contact dermatitis• Tissue graft rejection• Tuberculosis mycose

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ADVERSE DRUGS REACTION CLASSIFICATION

Directly extension of pharmacologic effect :Side effect, overdose, local toxic effect

Altered recepient (patient) :Presence pathologic processes, emotional disturbances, genetic abbernations (idiosyncrasy), teratogenicity, drugs interactions

Drug allergy

Adapt from Pallasch T.J in Stanley malamed, 2000.

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DEFINITION ALLERGIC REACTION

• Overdose rx. : a condition that result from exposure to toxic amounts of a substance that doesn’t cause adverse effect when administered in a smaller amounts.

• Allergy : hypersensitive response to an allergen to which that individual previously exposed and has antibodies developed.

• Idiosyncrasy : an individual’s unique hypersensitivity to a particular food, drugs/ other substance.

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CLASSIFICATION OF ALLERGIC DISEASEType Mechanism Antibody/cell Time reactions Clinical features

I Anaphylactic(antigen induced-antibody mediated)

Ig E Second to minutes

Anaphylaxis, atopic bronchial asthma, allergic rhinitis, urticaria, angioderma, hay fever

II Cytotoxic(antimembrane)

Ig GIg M (activate complements)

- Transfusion reaction, hemolytic anemia, autoimmune hemolysis, certain drug reaction

III Immune complex(serum sickness like)

Ig G (form complexes + complements)

6-8 hour Glomeluronephrosis, Lupus nephritis, acute viral hepatitis, serum sickness

IV Cell mediated - 48 hour Allergic dermatitis complex, tissue rejection, chronic hepatitis, TBC, mycosis

Based on Krupp., Chatton in Stanley malamed, 2000.

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• Allergic reaction is an exaggerated or inappropriate immune reaction and causes damage to the host

• Hypersensitivity:

– Type I: anaphylactic reaction: mediated by IgE antibodies, which trigger the mast cells and basophils to release pharmacologically active agents.

– Type II: cytotoxic reaction: IgM or IgG antibodies bind to antigen on the surface of cells and activate complement cascade.

ALLERGIC REACTION(Type)

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– Type III: Immune complex reaction: complexes of antigen and IgM or IgG antibodies accumulate in the circulation or in tissue and activate the complement cascade. Granulocytes are attracted to the site of activation and release lytic enzymes

– Type IV: cell-mediated immunity reaction: mediated by T cells, which release cytokines upon activation to cause accumulation and activation of macrophages.

ALLERGIC REACTION(Type)

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DRUGS INDUCED ALLERGY & IT’S SUBTITUTES

• Antibiotic…………………………………………..– Penicillins, Cepalosporins,

Tetracyclines, sulfonamides• Analgetic……………………………………………

– Aspirin, NSAIDs• Opioid……………………………………………….

– Morphine, meperidine, codein• Antianxiety…………………………………………

– barbituirates• LA………………………………………………………

– Esters: procaine• Other…………………………………………………

– acrylic

• Erythromycin

• Acetaminophen• Opioid – NSAIDs

• diazepam/flurazepam• Sodium bisulfite – non

vasopressor LA• Acrylic – heat curing/

avoid at all

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LOCAL ANESTHETIC OVERDOSEmild overdose with rapid onset

Sign&symptoms

1. Onset 5-10 min. after drug adm.

2. Talkativeness.3. Increased anxiety.4. Facial muscle twicthing.5. HR, BP, Rr increased.

managements

1. Terminate dental tx.2. Positition.3. Reassurance px.4. ABC.5. Treat & medication:

1. O2 adm.2. Vital sign monitoring3. Anticonvulsan?

Diazepam/midazolam 2,5-5mg iv

4. Emergency transport if no reacting.

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Sign & symptom• Tender to unconsciousness.• Appear as second after

inject adm.• Tonic-clonic seizures

1. Idem poin 1-5 above2. If iv unavaliable: BLS3. Vital sign monitoring: if BP

remains depressed (>30min.) consider to give vasopressor (20mg methoxamine im, 1000ml of normal saline/ dextrose 5% iv infusion)

4. Ready to emergency transfer if no response.

LOCAL ANESTHETIC OVERDOSEsevere with rapid onset

managements

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VASOCONSTRICTOR OVERDOSE

Clinical manifestations1. Increase BP, HR (palpitation)2. Fear3. Anxiety4. Tenseness5. Restlessness6. Tremor7. Headache/dizzyness8. Perspiration9. Pallor10. Respiratory distressed11. sweating

managements1. Idem poin 1-5 above2. If respiratory distressed : o2

canule, hood/full mask needed.

3. Vasodilators (optional) : BP HR doesn’t begin to return, nitroglycerin 2x spray translingual (beware of postural hypotension).

4. Ready to emergency tranport.

April 7, 2023

VASOCONSTRICTORS(COMMONLY USE)

Agents [ ] Dilutions Max dose Mg/ml Mg/Cartridges (1,8ml)

Max cartridges

Ephinephrine(lidocain 2%)

1:50K1:100K1:200K

--

1:100K

1:200K

H=0,2mgC=0,04mg

--

0,01

0,05

--

0,18

0,09

H=10; C=2

H=20; C=4

Stanley malamed,2000. 50

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Drugs Dose mg/kg Absolute max dose

Lidocaine 4.4 300 Lethal

Mepivicaine 4.4 300 Lethal

Prilocaine 6.0 400 Lethal

Bupivicaine 2.0 90 Lethal

Etido/articaine 7.0 500 lethal

VASOCONSTRICTORS(maximum dose)

Stanley malamed,2000.

April 7, 2023 52

BMJ Journals, visual diagnosis and critical care medicine., 2006

Skin rash / Urticaria

April 7, 2023 53

General Treatment1. ABC’s2. Maintain airway, administer oxygen, and

determine possible need for intubation or surgical airway.

3. Monitor vital signs.4. If in shock put patient in a horizontal or slight

Trendelenburg position.

ALLERGIC REACTION(Management)

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A. Insertion o2 maskB. supine/trandelenberg postioning


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Emergency statusallergic rx.

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ALLERGIC REACTIONskin reaction

• Terminated dental procedure

• Positioning• ABC• D: definitve care

– Observe– Histamine blocker oral

• Terminated dental procedure

• Positioning• ABC• D: definitve care :

– No cvs : poin 1.– CVS :1. Adm. Epinephrine (sc, im,

iv)2. Adm. Histamine blocker

Management rapid onset skin allergic reaction

Management elayed onset skin allergic reaction

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ALLERGIC REACTION


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SHOCKOther type allergy

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SHOCK

• Shock?– inadequency of blood flow throughout the body

to the extent that the body tissue are damaged because of too little flow, especially too little delivery of oxygen and other nutrients to tissue cell.

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SHOCK

HYPOVOLMIC CARDIOGENIC

ANAPHYLACTI

C

SEPTICEMIC

NEUROGENIC

DISTRIBUTIVE

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• Cause of shock– Reduced venous return following haemorrhage.– Cardiogenic shock from ischaemic heart disease

and cardiac contusions.– Reduced arterial tone complicates spinal injury

above T6 by impairing sympathetic nervous system outflow from the spinal cord below that level.

– Septic shock results when circulating endotoxins.

SHOCK

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PATHOGENESISHYPOVOLUMIC & SEPTIC

DECREASED EFFECIENCY CIRCULATING VOLUME

DECREASED VENUS RETURN TO HEART

DECREASED CARDIAC OUTPUT

DECREASED BLOOD FLOW

DECREASED SUPPLY OF OXYGEN

ANOROXIA

SHOCK

journal of dentistry, BMJ volume 111 no.2, februari 2003

April 7, 2023 63

Anaphylaxis: This is a severe systemic type allergic reaction and is a medical emergency.

Signs and symptoms include:1. Cardiovascular shock including; pallor, syncope, palpitations,

tachycardia, hypotension, arrythmias, and convulsions.2. Respiratory symptoms include; sneezing, cough, wheezing,

tightness in chest, bronchospasm, laryngospasm.3. Skin is warm and flushed with itching, urticaria, and

angioedema.4. Nausea, vomiting, abdominal cramps, and diarrhea also

possible.

..anaphilactic

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Management• Lay flat with raised legs• Give Adrenaline (1:1000) 0.3-0.5 ml SC or IM• Hydrocortisone 200 mg i.v.• Chlorpheniramine 10-20 mg slow i.v.• Give oxygen 6L/min & assisted ventilation• Consider Cricothyrotomy if NO quick

improvement?

..anaphilactic

April 7, 2023 65

Teratment.• For severe reactions, (i.e., collapsed, semi-conscious

patient, or those with severe bronchospasm and widespread rash) adrenaline given intramuscularly in a dose of 500 micrograms (0.5 mL adrenaline injection of 1:1000); an autoinjector preparation delivering a dose of 300 micrograms (0.3 mL adrenaline injection 1:1000).

• The dose is repeated if necessary at 5 minute intervals according to blood pressure, pulse and respiratory function.

anaphilactic

April 7, 2023 66

Consider diagnosis of anaphylaxis when compatible history of severe allergic-type reaction with respiratory difficulty and/or hypotension especially if skin changes present

Stridor, wheeze,respiratory distress or clinical signs of shock #2

For hypotension, lie patient flat with legs raised (unless respiratory distress increased)

Adrenaline 1:1000 solution

>12 years: 500 micrograms IM (0.5 mL) 250 micrograms if child is small or prepubertal #3 6-12 years: 250 micrograms IM (0.25 mL)

April 7, 2023 67

SIGNS AND SYMPTOMS VASOCONSTRICTORS TOXICITY

Adverse Drug ReactionsLocal Anesthetic and Epinephrine ToxicitySigns and Symptoms of Epinephrine Toxicity1. Agitation, weakness, and headache.2. Pallor, tremor, palpitation.3. Sharp rise in blood pressure and heart rate.

April 7, 2023 68

managements

MANAGEMENT OF TOXIC REACTIONS TO EPINEPHRINE: toxic effect ofepinephrine is transitory rarely lasting more than a few minutes

1. Stop dental treatment.2. Place patient in most comfortable position.3. Monitor vital signs.4. Consider administering oxygen.5. Allow time for the patient to recover.

April 7, 2023 69

LOCAL ANAESTHETICUM TOXICITY

Signs and Symptoms of Local Anesthetic Toxicity1. Agitation.2. Muscular twitching and tremors.3. Increased blood pressure and heart rate.4. Light-headedness.5. Visual and auditory disturbances (Tinnitis, Difficulty

focussing.)6. If moderate to high overdose of Local anesthetic can

also have convulsions and depression of blood pressure, heart rate, and respiration.

April 7, 2023 70

Managements

Treatment varies with the onset and severity of the reaction.MILD REACTION/RAPID ONSET (Example is an intravascular injection)

1. Reassure patient.2. Administer Oxygen.3. Monitor and record vital signs.4. Allow for recovery; determine if patient can be

allowed to leave unescorted.

April 7, 2023 71

Managements

• SEVERE OVERDOSE/RAPID ONSET, SEVERE OVERDOSE/SLOW ONSET

1. ABC’s.2. Administer Oxygen by mask at 10-15L/minute.3. Start IV if available (18 gauge catheter with Normal

Saline.)4. If needed and available administer anticonvulsant, Versed

2mg, then 1mg/min to effect (Monitor respiration.)5. Monitor and record vital signs.6. Allow for recovery and discharge with appropriate escort

or transport to hospital if required.

April 7, 2023 72

Max dose LA & vasoconstrictors

• Maximum Recommended Doses of Local Anesthetic• Lidocaine “Plain” 4.4mg/kg• Lidocaine 2% with 1:100k Epinephrine 7.0mg/kg• Mepivicaine “Plain” 4.4mg/kg• Mepivicaine with 1:20k Neocobefrine 6.6mg/kg• Bupivicaine with 1:200k Epinephrine 3.2mg/kg• Maximum Recommended Doses of Epinephrine• Healthy Adult 0.2mg• Cardiac Patient 0.04mg

April 7, 2023 73

HEART DISEASE

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AnginaSigns and Symptoms of Angina1. Sub-sternal/retro-sternal pain that spreads across the chest and

may radiate to arm/shoulder any area above the diaphragm.2. May vary from a heavy squeezing pain to a pressure or heavy

sensation in the chest.3. Pain usually lasts for a few minutes and disappears with rest;

can last for up to 60 minutes.4. Other symptoms such as palpitations, faintness, dizziness,

dyspnea, and digestive disturbances may accompany angina.5. vomit?

Signs and symptoms

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MANAGEMENT OF ANGINA1. Stop all treatment and stimulation of the patient.2. Position the patient comfortably; sitting upright is usually

preferred.3. Administer Oxygen via mask at 10-15L/min.4. Administer one tablet of Nitroglycerin 0.4mg sublingual or

one metered dose spray. If using tablets do not touch use gloves. Nitroglycerin can be absorbed through the skin.

5. If no relief after two minutes repeat Nitroglycerin. Can repeat a third time if no relief. Monitor blood pressure after each dose; do not repeat dose if systolic BP drops below 100.

6. Monitor and record vital signs.7. If no react after given 3rd dose nitro, susp. MI?

managements

April 7, 2023 76

Miocard infark

Signs and Symptoms of a Myocardial Infarction (Heart Attack)1. Often preceded by a history of angina.2. Pain usually described as heavy, squeezing, pressing, or

crushing in nature. Pain is located over middle third of sternum.

3. Pain is not relieved by nitroglycerin and is longer in duration than angina (Angina generally last 30 minutes to one hour.)

4. Silent MI (No pain) occurs in 15-20% of cases though they may suffer from nausea, vomiting, weakness, and anxiety.

April 7, 2023 77

5. weakness, diaphoresis, and hypotension.6. Patient is often restless, moving about in an attempt to find a

comfortable position.7. Dyspnea is present as patient complains that crushing pressure prevents

normal breathing.8. Levine’s Sign.9. Shock occurs in 20% of cases.10. Cardiac arrhythmias occur in 95% of patients suffering from a MI.11. Arrhythmias usually occur within the first two hours after onset of the

MI.12. Ventricular fibrillation is the most common arrhythmia. This is an

uncoordinated contraction of individual muscle bundles within the myocardium resulting in the inability of the heart to pump blood.

13. Cardiac arrest is the result and must be converted to a normal rhythm as soon as possible.

Signs and Symptoms of a Myocardial Infarction (Heart Attack)

April 7, 2023 78

MANAGEMENT OF A SUSPECTED MYOCARDIAL INFARCTON1. Discontinue all treatment2. Clear the mouth of all foreign material.3. Place patient in a comfortable position (Usually upright.)4. Administer Oxygen at 10-15L/min.5. Monitor and record vital signs every 5 minutes (Including

blood pressure, pulse, and respiration rate).6. Give the patient an aspirin (325mg) if available and have them

chew it and allow it to absorb through the oral mucosa.7. If equipment available start an IV (18guage catheter with

Normal Saline.)

managements

April 7, 2023 79

8. If equipment available attach cardiac monitors.9. If a provider is properly trained and equipment is

available proper ACLS protocols should be initiated.11. If patient looses consciousness initiate proper BLS

protocols.TRANSPORT: In the case of a MI the earlier the

patient is transported to a hospital and definitive treatment begun the better the chance the patient will survive with minimal cardiac damage.

April 7, 2023 80

Emergency statusangina (heart attack)

April 7, 2023 81

April 7, 2023 82

DIABETICPre operative

April 7, 2023 83

Emergency statusPRE OPERATIVE

• DM– Acute complication : hyper/hypoglicemia– Chronic complication : arteriosclerosis,

microangiopathiWhat is normal value of normal glucose tolerance?Fasting plasma glucose(mg/dL) = <115Tolerance 116-139>140 = diabetic

• In nondiabetic patients, 2-hour postprandial blood glucose levels are usually <120 to 140 mg/dL.


April 7, 2023 84

• DM classification– DM type I : IDDM– DM type II : NIDDM

• Non obese• Obese

– Other type : associated with other condition and syndrome (pancreatic disease, hormonal ethiology, drug induced, insulin receptor, abnormalities, genetic/pathologic syndrome)


Emergency statusPRE OPERATIVE

April 7, 2023 85

Normal Values• Normal fasting glucose: FPG<100 mg/dL (<5.6

mmol/L SI units)• Impaired fasting glucose: FPG 100–125 mg/dL

(5.6–6.9 mmol/L SI units)• Provisional diagnosis of diabetes: FPG ≥126

mg/dL (≥ 7.0 mmol/L SI units) (diagnosis must be confirmed)

PRE OPERATIVEdiabetic


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• Glucagon:causes the blood sugar to rise by speeding the breakdown of glycogen in the liver.

• Insulin allows : glucose to pass into cells for use as energy, leading to a decrease in the blood glucose.

• The maintenance of normal blood glucose is dependent upon proper functioning of two hormones.


April 7, 2023 87



Blood glucose check

April 7, 2023 88

Robins & cotrans, 2003

April 7, 2023 89

HYPERGLICEMIA

• Chronically ill.• Dry appearance, warm skin.• Odor acetones breath.• Blood Glucose level >250 mg/dl.• Blood pH ,7,3• Usually develop over a period many hour/day.• Kussmaul’s respiration.• Altered level of consiousness.

April 7, 2023 90

HYPERGLICEMIAMANAGEMENTS

Hyperglycemia (unconscious)

1. Terminate dental tx2. P: Positioning supine3. ABC: BLS needed4. D: Definitive initiating

care, maintain O2, establish IV, tranfer to Hospital if no response

Hyperglycemia(conscious)

1. Clinical sign&symptom recognized(level ASA4) : hi risk, shouldn’t receive dental tx

2. Medication& supportive tx.

3. Consult?

April 7, 2023 91

Optimal ASA physical status to diabetic conditions management

• Type I IDDMinsulin+diet control

• Type II NIDDM non obeseinsulin+diet control

• Type II NIDDM non obeseOral medication+diet control

• Type II NIDDM obeseoral medication+diet control

III severity………………

II-III moderate to severe………………..

II mild to

moderate…………..

II mild to moderate…………..

Stanley malamed, 2000ASA: american society of anesthesiologists

April 7, 2023 92

GLUCOSE LEVELTO TREATMENT MEASUREMENTS

Urine glucosuria Blood glucose Physical status Comment0 <50 mg/dl + 1 May accept tx,

might become hypoglicemic

0+1+2

80 mg/dl120 mg/dl180 mg/dl

000

Accept dental tx

+3 240 mg/dl +1 Evaluate before tx

+4 >240 mg/dl +2 Medical consult before tx.


April 7, 2023 93

HYPOGLICEMIA

• Insulin shock?• Weakness, dizziness, pale, moist skin.• Normal/depressed breath.• Headache.• Altered level conscious.

April 7, 2023 94

HYPOGLICEMIAmanagements

Conscious&responsive px.1. Initial recognition2. Termination dental tx3. Potition (individual px.

Comfort, common up right)4. ABC5. D: definitive care, oral

carbo.?, observe

Unresponse conscious px.1. Idem to poin 1-52. If no response, parenteral

carbohydrates : glucagon 1mg/im/iv. 50ml of dextrose sol. Iv, 2-3 minutes. 0,5mg of 1:1000 ephinephrine sc/im, 15 minutes (careful to cardiovasc disease).

3. Monitoring px status, vital sign review.

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Anti hypoglicemia preservation


Anti hypoglicemic agents

A

B

C

D

A. Dextrose inj. 50%B. Glucagon inj.C. Epinephrine inj.D. sugar


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• Hypoglicemia drugs & kit


a. Infusion set+glucose 20%b. Glucose 50% in minijet formatc. Glucose powder 20 grd. Glucagon emergency sete. Blood glucose test stickf. Oxygen mask


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LONG TERM COMPLICATION OF DIABETIC


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ASTHMAEmergency systemic conditions

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asthma

• Is: chronic inflammatory disorders of the airway in which many cells and cellular elements play role.

• Chronic inflammation due to associated with hyperresponsiveness that leads to recurrent episodes of wheezing, breathlessness, chest tightness and coughing.

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• Asthma attackSigns and Symptoms of an Asthma Attack1. Sense of Suffocation, patient will sit up like they are fighting

for air.2. Pressure or tightness in chest.3. Non-productive cough.4. Expiratory and inspiratory wheezes.5. Expiration is prolonged and harder than inspiration.6. Chest is distended.7. Thick Stringy mucous. At termination of a period of intense

coughing the patient will expectorate this mucous.

Emergency statusdurante op.

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• Severe symptoms– Cyanosis– Perspiration and flushing of the skin.– Use of accessory muscle of respiration:

Sternocleidomastoid, and shoulder/abdominal muscles.

Emergency statusasthma

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Management1. Discontinue dental treatment.2. Place patient in easiest position for them to breath.

This is usually upright with arms outstretched.3. Albuterol Inhaler (Proventil) 2 puffs every 2 minutes.4. Supplemental oxygen at 10L/min.5. Consider Epinephrine 1:1,000, 0.3g every 20 minutes.6. Monitor vital signs.


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• If we already knew our px medical history1. Take a good Medical History prior to

treatment; determine how often the patient has an asthma attack and what precipitates it.

2. Consider scheduling morning appointments.3. If patient uses an inhaler they should have it

on hand during treatment. Consider prophylactic use prior to treatment.


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TRAUMATIC INJURY

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Emergency statusTraumatic injury

Primary survey:• Airway with cervical spine control• Breathing• Circulation with hemorrhage control• Disability• Exposure and environmental control

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109

Emergency statustraumatic injury

a. Mastoids hematoma

Gus, M. Garrel. , 2005b. hemotympanum

c.

(C).

(A).

(B).

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Malocclusion, indicated maksila/mandible/dentoalveolar fractures

Gus, M. Garrel. , 2005

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Mechanism of traumatic and possible injuries


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Emergency statustraumatic injury

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Safety 1st

wear and click ur helmet

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Emergency statuspost op.

• Bleeding• Trismus• Dry socket• Oro antral fistula

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Drugs, emergency kit and preservation equipments

• O2 & mask

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Asthma emergency kit

• Aerosol inhaler• Aminophilline 25

mg/mL• Isoproterenol 1mg/5 ml• epinephine

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Antihypoglicemic agents

• Dextrose• Glucagon• Epinephrine• sugar

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Blood gucose check

• Blood glucose tools

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unconsious

• Inhaler amonia

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SEIZURESunconsiousness

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etiology

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Predisposing factors

• Predisposing factors:• Anxiety• Hunger• Menstruation• Alcohol• External stimuli, flashing lights• Etc• Non compliance with• medications

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Signs and symptoms

• Warning cry• Immediate loss of consciousness• Rigid (tonic phase)• Widespread jerking (clonic phase)• Vomiting• Flaccid after a few minutes• Consciousness is regained after a variable Period• Patient may remain confused

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• Prevent patients from damaging• themselves• Place in Supine position• Maintain patent airway• No medications, await recovery• Recovery position after fits have ceased• Suctioning & Monitor VS• Oxygen• Reassure on recovery• After fully recovered requires an escort• Continuous or repeated convulsions for 15• minutes (patient can have severe anoxia)• Give 10mg Midazolam IV repeat if no• recovery within 10 minutes• Maintain airway & give oxygen• Call an ambulance, transfer to hospital

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managements

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Drugs treatment

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Algoritm for seizures evaluation

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Differential dx

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• Clinical Surgery in General 4th ed. R.M.Kirk., W.J.Ribbans., Elsevier. 2004.

• Clinical problem solving in dentistry, 2nd ed. edward w. odell. Curchill livingstone., 2001.

• Stanley f. malamed., 2000.• John E Rowson, Adrian E Slaney, dentistry., cavendish pub.1996.• visual diagnosis in emergency and critical care medicine, bmj

books., blackwell pub.ltd.2006.• denise d. wilson., manual of laboratory and diagnostic tests.,

mc.graw hill. Company., 2008.• s.v.mahadevan., gus m. garrel., clinical emergency medicine.

Cambridge press. 2005.

Documents

Medical Emeregency