MEDICAL EMERGENCIES IN DENTAL OFFICE
By-Sai Lakshmi RaoIII BDS
Geetanjali Dental & Research Institute, Udr
CONTENTS IntroductionTypes of Emergencies* Prevention* Preparation* ManagementSummaryConclusionReference
INTRODUCTION
◘ What is an emergency?
A serious and unexpected situation requiring an immediate action.
It is an unforeseen combination of circumstances or the resulting state that calls for an immediate action.
TYPES OF EMERGENCIES UNCONSIOUSNESS• Syncope• Hypotension• Hypoglycemia
SEIZURES
RESPIRATORY EMERGENCIES• Airway obstruction• Asthma
CARDIOVASCULAR EMERGENCIES• Angina pectoris• Myocardial infarction
DRUG-RELATED EMERGENCIES• Overdose reactions• Allergies
Most comm
on Emergencies
Syncope
Seizure
Trauma
AsthmaticattackChest
painDrug toxicity
Airwayobstruction
Allergies
Hypoglycemia
SYNCOPE• Syncope is a short loss of consciousness
and muscle strength, characterized by a fast onset, short duration, and spontaneous recovery.
Causes H Hypoxia / HypoglycemiaE EpilepsyA Anxiety D Disorders of brain stem
H Heart attackE EmbolismA Aortic stenosisR ArrhythmiasT Tachycardia
CNS causes
CVS causes
V Vasovagal causes ( common faint)E Electrolyte abnormalities (ex.
hypercalcemia)S Situational (cough, sneeze, micturation)S Subclavian steal syndromeE ENT causes (glossopharyngeal neuralgia)L Low systemic vascular resistanceS Sensitive carotid sinus
Vascular and other causes
Symptoms Breathing – irregular, jerky & gasping Dilated pupils Convulsive movements Bradycardia (<50 beats per minute) Weak thready pulse Loss of consciousness Partial or complete airway obstruction
Management Position: supine position with brain and heart at
same level with feet elevated slightly (10 – 15 degrees).
ABC: basic life support as needed.
Definitive management: -monitor vital signs -administer
aromatic ammonia -administration of
atropine(0.1g/ml)
SEIZURE• It is a paroxysmal disorder of
cerebral function characterized by an attack, involving changes in the state of consciousness, motor activity or sensory phenomena.
• Usually sudden in onset and of brief duration.
• EPILEPSY: “A chronic disorder in which nerve cell activity in the brain is disturbed, causing seizures”.
Common symptoms of seizures
PREVENTION If a patient is known epileptic, make sure
he/she has taken their regular dose of anti-convulsant on the day of treatment.
Instruct him/her to alert you as the aura of the impending seizure manifests itself.
Keep life support equipments ready, in case of an emergency status epilepticus.
MANAGEMENT Self limiting emergency Position: supine with patient placed on flat
surfaces. Remove dangerous objects from the mouth
and around the patient.(ex. sharp instruments, needles, etc.)
Loosen any tight clothing. Avoid restraining the patient. In case the ictus fails to subside within a
maximum of 10 minutes, declare status epilepticus and proceed with definitive care.
DEFINITIVE TREATMENT
Diazepam – 10 mg i.v. , (2mg/min) repeat every 10 minutes.
Phenobarbitone – 100-200 mg/min, i.v.
Carbamazepine Phenytoin
HYPOGLYCEMIA• Hypoglycemia is a clinical syndrome in
which low serum (or plasma) glucose levels lead to symptoms of sympatho-adrenal activation.
Empty stomach/ Morning insulin
Low blood glucose level (<50mg/100ml)
Anxious disposition
Weakness/ dizziness, pale skin, depressed respiration
Loss of consciousness/syncope
Common symptoms
MANAGEMENT Glucose and sugar-containing beverages
administered orally to conscious patients for rapid effect.
Alternatively, milk candy bars, fruit, cheese, etc may be adequate in mild cases.
IV dextrose is indicated for severe hypoglycemia, in patients with altered consciousness and during any restriction of oral intake.
TREATMENT
20-25 ml of 50% dextrose should be given immediately.
Glucagon, 1mg i.m. (or s.c.) Metformin Sulfonylureas
RESPIRATORY EMERGENCIES
Airway obstruction◘May occur due to:o Pathology on the airwayo Dental instrumentso Tongue◘Patient demonstrates symptoms
ranging from coughing, gurgling, gagging, to choking & gasping with pain.
◘Aspired object may pass into the trachea or oesophagus.
PREVENTION
Rubber dam Oral packing Chair position Dental assistant Magill’s intubation forceps
MANAGEMENT◘ Re-establishment of airway:Non-invasive procedures Forceful coughing Back blows Heimlich maneuver Chest thrust Finger sweeps
HYPERVENTILATION• Excessive rate and depth of respiration leading
to abnormal loss of carbon dioxide from the blood primarily predisposed to stress and anxiety.
• Characterized by: Rapid short strained breaths Cold sweats Palpitations Dizziness Chest muscle fatigue
PREVENTION
Exhaled air is inhaled-in again using a paper bag. The point of breathing into a bag is to “re-breathe” your exhaled CO2 to bring the body back to a normal state.
Reduce patient’s stress and anxiousness by any means. The operator should stay calm and also make the patient be relaxed.
MANAGEMENT Administration of Benzodiazepenes:
-Diazepam (2-5 mg i.m./i.v. every 3-4 hourly)
-Lorazepam (2-3 mg oral per day, BD/TD)
-Triazolam (0.25 – 0.5 mg)
-Alprazolam (0.25 – 0.5 mg oral TD)
ASTHMA• A clinical state of hyper reactivity of the
tracheobronchial tree, characterized by recurrent paroxysms of dyspnea and wheezing.
MANAGEMENT
Position pt upright or bending forwards with arms straight ahead
Administer bronchodilators
Asthma terminates?
Yes No
Continue dental
procedure
Declare status asthmaticus
Summon EMS
Recognize symptoms
Stop dental procedure
CARDIOVASCULAR EMERGENCIES
Myocardial infarction• It is a clinical syndrome
caused by deficient coronary arterial blood supply resulting in ischemia to a region of the myocardium and causing cellular death and necrosis.
• Predisposing factors: - atherosclerosis, coronary
artery disease - coronary thrombosis,
occlusion and spasm - undue stress
PREVENTION Avoid overstressing the patient Supplemental oxygen during the treatment Pain control during therapy (appropriate
use of local anesthesia) Psychosedation Elective dental care is avoided until atleast
6 months after MI IA and PSA nerve blocks should be avoided
due to high risk of hemorrhage.
MANAGEMENT Antiplatelet agents-Clopidogrel (75 mg oral OD)-Ticlopidine (250 mg PO q12 hrs)Dipyridamole (75-100 mg oral TD)
Beta-blockers-Propranolol(40 mg oral TD)-Metoprolol (100 mg oral BD)-Atenolol (50 mg oral BD or 100 mg oral
OD)
Angina pectoris• A condition marked by severe pain in the
chest, often also spreading to the shoulders, arms, and neck, owing to an inadequate blood supply to the heart.
• Types: - Stable - Variant - Unstable
PREVENTION
Stress reduction
Reassurance
Psychosedation
MANAGEMENT Recognize the problem Discontinue dental treatment Activate office emergency team Position patient upright comfortably Assess and perform BLS Definitive management Use Beta-blockers
Drug-relatedemergencies
Overdose reactions• An overdose is when a person ingests or
takes in more than normal of recommended or prescribed amount of drug. It can be accidental or intentional.
• In a dental practice, most common overdosage is by local anesthesia.
SYMPTOMS
Confusion, talkativeness, blurred speech Muscular twitching, facial tremor Headache, tinnitus Drowsiness, disorientation Elevated BP, HR, RR If uncontrolled, generalized tonic clonic
seizures, generalized CNS carbopathy
MANAGEMENT
Administer BLS as needed 100% oxygen, anticonvulsants Allow recovery to occur In case of continuation of symptoms,
summon EMS
allergy• It is a hypersensitive state of skin and
various mucosae acquired through the exposure to a particular allergen, re-exposure to which produces a heightened emergent capacity to react.
• Occurring via expression of IgE in response to allergen exposure.
Symptoms
Red, itchy, watery eyes
Sneezing, congestion, runny nose
Itchy or sore throat, postnasal drip, cough
MANAGEMENT
Reassure the patient Initiate the BLS as needed Administer antihistaminics
(diphenhydramine 50mg), epinephrine 0.123-0.3 ml of 1:1000 i.m. or
s.c. Monitor vitals regularly
CONCLUSION
As the saying goes, “PREVENTION IS BETTER THAN CURE”.
ALWAYS BE PREPARED.
Prompt recognition and efficient management of medical emergencies by a well-prepared dental team that can increase the likelihood of a safe & a satisfactory outcome.
Basic life support training – A MUST.
REFERENCES
Stanley F. Malamed, Handbook of Local Anesthesia, 6th edition
James R. Hupp, Contemporary Oral and Maxillofacial Surgery, 6th edition