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Medical and dental emergencies and complications in
dental practice and its management
The medical and dental emergencies that are commonly encountered in dental practice involve:
syncope,
airway obstruction,
anaphylaxis,
local anesthetic toxicity,
Asthmatic attack,
chest pain,
hemorrhage,
seizure.
Myocardial
infarction and cardiac arrest are extremely rare.
SYNCOPE
Syncope is caused due to inadequate cerebral perfusion.
Causes of sudden loss of consciousness and collapse include
hypotension,
adrenal crisis,
anaphylaxis,
cardiac arrest,
diabetic collapse, hypoglycemia, epileptic seizure, fainting,
or stroke
THE EARLY MANIFESTATIONS
nausea,
warmth,
perspiration,
baseline blood pressure,
and tachycardia
LATE MANIFESTATION
hypotension,
bradycardia,
pupillarydilation,
peripheral coldness,
visual disturbance
MANAGEMENT:
The patient should be in the supine position
Recovery is almost instantaneous if the
patient has simply fainted.
Then maintain airway, check pulse (if
absent,
indicates cardiac arrest), and start CPR
immediately
SYNCOPE MANAGEMENT : TRENDELENBURG
POSITION
AIRWAY OBSTRUCTION
Airway obstruction is usually caused due to accidental slippage,
aspiration of foreign objects,
or laryngeal spasm. Patient
manifests with :
inability to speak, grasps the throat (universal
sign), coughs, inability to exchange air (in spite of respiratory movements), cyanosis, and loss of consciousness. These might eventually lead to cardiac arrest finally.
MAMAGEMENT
Main priority is to clear the airway, but the
method differs depending upon whether the
patient is conscious or unconscious.
If the patient is conscious, then
he/she must be made to sit straight, support chest with one
hand, and deliver five sharp back blows between the shoulder blades with the heel of the other hand. But if the patient is choking, an attempt is made to expel the object with upward
thrusts using Heimlich thrust [Figure 3]. It acts as artificial cough that produces a rapid increase in intra-thoracic pressure
thus helping to expel the foreign body [Figure 4].
FIGURE 3
ASSESS SEVERITY FIGURE 4
Encourage cough and observe the
patient for ineffective cough
Sever airway obstruction(ineffective cough
Mild airway obstruction
(effective cough)
Unconscious start CPR
Conscious 5 back blow 5 abdominal
thrust
ANAPHYLAXIS
It is a hypersensitive state that results from
exposure to an allergen.
The most common allergen in a dental setup
is latex
MANIFESTATIONS
vary from a mild form where the patient presents with :
erythematous rash,
cyanosis, nausea,
vomiting,
tachycardia,
utricaria,
or angiodema
to a severe form which leads to:
airway obstruction or inadequate blood pressure and blood flow to the brain which is a life-threatening situation
MANASGEMENT
involves lying the patient in the supine
position with legs raised
, administer oxygen, and the drug of choice
being 0.5 ml of 1:1000 adrenaline IM or SC
MANAGEMENT OF ANAPHYLAXIS
LOCAL ANAESTHIA TOXICITY
Toxicity is usually either due to the local
anesthetic itself or the vasoconstrictor which
can be due to rapid infusion or failure to
aspirate before injection
GENERALLY
the reactions are self limiting. Toxicity
presents with :
talkativeness,
slurred speech,
anxiety,
confusion,
drowsiness, or even seizure and cardiac
arrhythmias in extreme cases.
monitor vital signs.
Administer oxygen and in adverse cases
administration of diazepam 5 mg slowly is
advised
ASTHMATIC ATTACKE
Anxiety, infection, exposure to an allergen or
drugs can precipitate an asthmic attack
The goal of management during an acute
asthmatic episode on a dental chair should
be to:
relieve the bronchospasm associated with
the attack
Hence, the patient should primarily be
relieved of irritants and all articles should be
removed from oral cavity.
Drug of choice is 2 puffs of albuterol
(bronchodilator)
. If no improvement isseen in 15 seconds
then administer 1:1000 adrenaline 0.5 ml
SC/IM and
if still no response is observed in 2-3 min
then
salbutamol slow IV injection is advised.[
CHEST PAIN
Factors that precipitate chest pain include:
angina,
acute myocardial infarction,
gastrointestinal reflux disease,
anxiety,
costochondritis and paroxysma
supraventricular tachycardia
Taking history from patients is very important
here
Quality of pain can also indicate whether the
patient is having
an angina or acute myocardial infarction. In
angina pectoris pain is significant but not
severe
whereas an acute myocardial infarction pain
generally radiates to left side of the body-left
shoulder, left mandible, left arm.[
For angina pectoris, drug of choice is a nitrate,
commonly nitroglycerine, sublingual tablet,translingual or transmucosal spray.
Management of a patient with suspected acutemyocardial infarction involves administration of
morphine, oxygen, nitroglycerine, and aspirin(MONA)
in addition to emergency medical service. If morphineis
unavailable, the specialist can also substitute nitrousoxide/oxygen in a 50:50 concentration
HEAMORRHAGE
as dental specialists deal with blood routinely and there are instances when significant bleeding could lead into an emergency. Emergency management begins by :
gently cleaning the mouth and locating the source of bleeding
and the application of cold compress,
pressure packs, or styptics(substance capable of stopping bleeding when applied to a wound)
.Suture the area under L.A when necessary.
Tranexamic acid –500 mg in 5 ml by slow IV injection is the drug ofchoice
SEIZURES
Patients who convulse in dental office
generally have a seizure history and are
often characterized as having epilepsy
MANAGEMENT
Place him in a spine position
Remove all instrument from his mouth
Clear airway
Loosen the closthes
If seizure continues for long, then the
condition is known as status epilepticus. This
is a life-threatening emergency and is best
managed with
I.V. diazepam 5 mg IV/IM or
by maintaining BLS( basic life support) till
patient is shifted to emergency medical care.
DM
Elevated glucose levels in blood and urine.
Persons diagnosed with Diabetes may suffer
from too high or too low blood sugar at times
depending on medications, food intake,
illness or stress
SIGN AND SYMPTOMS
Hypoglycemia: Hyperglycemia
- Rapid onset –within minutes - Slow Onset – hours or days or weeks
(can be fatal) - Hot, dry
- Nervousness - Flush malaise
- Pallor - Nausea vomiting
- Weak, dizzy - Stupor
- Hunger, nausea - Drowsy
- Mental confusion - Irritability
- Lethargy or belligerence - Headache
- Decreased rate of breathing - Acetone odor
- Increased heart rate - Decreased rate of breathing
- Decrease in blood pressure - Increased heart rate
- Seizures - Decrease in blood pressure
- Tingling sensation in feet/hands
- Loss of consciousness, coma
Treatment Precautions:
• Ensure patient has eaten and has had their medication before the appointment
• Keep appointments short
• Have a sugar supplement on hand
Treatment:
• If conscious and able to swallow well, give sugar supplement. Call EMS if patient doesn’t feel better
in 15 minutes or becomes unconscious.
• If unconscious call EMS immediately
Situation Agent Regimen
Standard general
prophylaxis
Amoxicillin Adults: 2g
Children: 50mg/kg
orally
1 hour before the procedure
Inability to take oral
medications
Ampicillin Adults: 2g
Children: 50 mg/kg
IM/IV
30 min before procedure
Allergy to penicillin Clindamycin or
Cephalexin/Cefadroxil or
Azithromycin/
Clarithromycin
Adults 600 mg
Children 20 mg /kg
Adults 2g
Children 50mg/kg
Adults 500 mg
Children 50 mg/kg
Orally
1 hour before the procedure
Allergy to penicillin and
inability to take oral
medications
Clindamycin or
Cefazolin
Adults 600mg
Children 20mg/kg
IV 30 min before
Adults 1g
Children 25 mg/kg
IM/IV 30 min before
BASIC LIFE SUPPORT (BLS)
Module one – critical or essential emergency drugs
Category Generic drug alternative quantity Availability
Allergy –
anaphylaxis
Epinephrine None 1 preloaded
syringe +3x1
ml ampules
1:1000
(1mg/ml)
allergy –
histamine
blocker
Chlorphenira
mine
Diphenhydra
mine
(Benadryl)
3x1 ml
ampules
10 mg/ml
Oxygen Oxygen 1 “E” cylinder
Vasodilator Nitroglycerin Nitrostat
sublingual
tablets
1 metered spray
bottle
0.4 mg /metered
dose
Bronchodilator Albuterol Metaproterenol 1 metered dose
inhaler
Metered aerosol
inhaler
Antihypoglyce
mic
Sugar Insta – glucose
gel
1 bottle
Inhibitor of
platelet
aggregation
Asprin None 2 packets 325mg/tablet
Module two – secondary/ noncritical drugs and equipment
Category Generic Drug Alternative Quantity Availability
Anticonvulsant Midazolam diazepam 1x5 ml vial 5 mg/ml
Analgesic Morphine
sulphate
Meperidine 3x1 ml ampules 10 mg/ml
Vasopressor Phenylephrine 3x1 ml ampules 10 mg/ml
Antihypoglycem
ic
50% dextrose Glucagon 1 vial 50 ml ampule
Corticosteroid Hydrocortisone
sodium succinate
Dexamethasone 2x2 ml mix- o –
vial
50 mg/ml
Antihypertensive Esmolol Propranolol 2x100 mg/ml
vial
100 mg/ml
Anticholinergic Atropine Scopolamine 3x1 ml ampules 0.5 mg/ml
Respiratory
stimulant
Aromatic
ammonia
2 boxes 0.3 ml/vaporole
Antihypertensive Nifedipine 1 bottle 10mg/capsule
Module three – Advanced Cardiac Life Support (ACLS) : essential
drugs
Category Generic Drug Alternative Quantity Availability
Cardiac Arrest epinephrine 3x10 ml
preloaded
syringes
1:10,000
(1mg/10ml
syringe)
Analgesic Morphine
sulphate
N2O – O2 3x1 ml ampules 10 mg/ml
Antidysrhythmic Lidocaine Procainamide 1 preloaded
syringe and 2x5
ml ampules
100 mg/ syringe
Symptomatic
Bradycardia
Atropine Isoproterenol 2x10 ml
syringes
1.0 mg/10 ml
Paroxysmal
Supraventricular
Tachycardia
verapamil 2x4 ml ampules 2.5 mg/ml
Establishing an emergency airway –
Non invasive procedures
Invasive procedures
example of how to place an unconscious
patient into the lateral recovery position – always ensure that the chin is
in an elevated position to maintain airway patency
DENTAL COMPLECATIONS
More than dental emergencies which require
an immediate attention and management,
the occurrence of “complications” are of
higher incidence in dental practice. The
complications may be immediate or delayed
and are related to patient’s tolerance level,
materials used and treatment procedures
ASPIRATION
Aspiration may be of:
the denture as a whole or a fractured part, a
minimal extension acrylic
removable prosthesis,
crowns during removal, I
nstrument
slippage especially broaches reamers or
files.
Aspiration causes:
airway obstruction which is manifested as the
universal sign“choking.”
Removal of broken instruments is performed
using:
ultrasonics, operating microscopes or
microtube delivery methods.
ALLERGY
Allergy can be to latex, mercury, rubber dam, and impression material
Manifestations of allergy include
pruritis,
erythema,
utricaria,
and angioneurotic edema.
latex-sensitive patients. Latex alternatives
(vinyl, nitrite, or silicone) and powder-free
gloves should be used to prevent
sensitization
Fixers like formacresol and devitalizers to be
used carefully to prevent chemical burns.
Complications involving local anaesthetics
are hypersensitivity, toxic reactions
MANAGEMENT
administering prophylactic antihistamines,
such as diphenhydramine
or corticosteroids such as prednisone before
dental treatment to those at known
Risk
and the drug of choice is 0.3-0.5 ml
intra-muscular or subcutaneous doses of
1:1000 epinephrine
Allergic reactions can also occur to acrylic
resins, which can be minimized by:
following proper monomer polymer ratio,
correct curing cycle so as to minimize the
residual monomer content in the prosthesis
PACEMAKERS AND THE DUAL-CHAMBER ICD
Operation of:
the electric toothbrush,
electrosurgical unit,
electric pulp tester,
high- and low-speedhandpiece, and an amalgamator did not alter pacing function.
the use of the ultrasonic scaler,
ultrasonic cleaning system,
battery-operated composite
curing light may produce deleterious effects in patients who
have pacemakers or ICDs.
HYPOCHLORITE ACCIDENT
wherein sodium hypochlorite is expressed
beyond the apex and patients manifests with
severe pain,
swelling
profuse bleeding.
MANAGEMENT
administration of a regional block and then
wait till maximum drainage occurs.
Antibiotics:
Penicillin 500 mg five times a day for 7 days
is prescribed.