medical emrgencies in dental practice

Medical Emergenciesin

Dental Practice

Prepared by: Dr . Aia Al-Marsumy

What is an Emergency situations? Common Emergency Situations are

Fainting (Vasovagal Syncope )Diabetic ComaAnaphylactic ShockEpileptic SeizuresCardiovascular Collapse (CVC)Thyroid CrisesAdrenal CrisesAsthmatic AttackStroke (Cerebro-vascular Accident, CVA

emergencies: Clinical Presentation of

-Sudden loss of consciousness

-Chest pain & dyspnea

-Convulsions (fits)

Basic Emergency Procedures - Monitor BP and pulse

Clear, secure & maintain Airway cardiopulmonary resuscitation

intravenous cannulation ↓

Basic Life Support (BLS) A- Airway

B- Breathing C- Circulation

Collapse

• shock• Steroid crisis• Myocardial Infarction• Cardiac Arrest• CVA

Acute Chest Pain or Difficulty ofBreathing

Angina

Myocardial Infarction

Asthma

Anaphylactic Shock

ConvulsionsEpilepsy

Any other cause of loss of consciousness

including fainting

Fainting

•Predisposing factors:

Stress Conditions AnxietyPain

InjectionFatigueHunger

Pathophysiology

Stress↓

Release of catecholamine↓Changes in tissue blood perfusion; decreased peripheral vascular resistance, increasedblood flow to tissues↓leads to pooling of blood in tissue

↓fainting

Mechanism

• Signs & Symptoms Premonitory dizziness, weakness & nausea

Pale, cold moist skin

Pulse initially

Management

•Lay flat & lift legs

•Loosen tight clothing around neck

»Give sweetened drink on regainingconsciousness

•Prolonged fainting, atropine 600 mcg/ml slow iv (1 ml only)

prevention• Good history

• Reassurance

• General Anxiety (Stress) Reduction Protocol

• Well fed prior to treatment

• Glucose drink

10 mg Temazepam nocte (prior to appt) & 1hour before treatment

• Delay the procedure

Anaphylactic shock• Drugs e.g. penicillin

• Insect stings

• Foods, nuts, shellfish, materials

Quicker onset the more severe the reaction

• Widespread vasodilatation & increase incapillary permeability, potentially fatal

• Hypotension

Hypersensitivity Type I

-Immediate -IgE mediated

-Anaphylaxis -Urticaria

-Angio-oedema -Allergic Asthma

-Rhinitis

Adverse Reactions

• Hypersensitivity

• Angio-oedema

Anaphylaxis•

• Signs & Symptoms variable

Rapid weak or impalpable pulse

• Facial flushing, itching, tingling, cold extremities

• Bronchospasm (wheezing)

• Loss of consciousness

Pallor going on to cyanosis

Cold, clammy skin

Facial oedema & sometimes urticaria

Deep fall in BP

Management of Anaphylaxis•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•

•Call an ambulance

Accidental swallowing of foreign bodies

• A case of swallowed dental root canal instrumentEsophagogastroduodenoscopy

•needle-like foreign body sticking deep in the duodenal wall

• the object was removed by forceful extraction with a rat tooth forceps and identified as a dental root canal instrument, distinctly changed by gastric acid.

Extracted instrument

Original instrument

• The patient then remembered that the pain was started after a dental root canal treatment under local anesthetics.

• The pain was probably due to the irritation of the duodenal wall by needle while moving the upper part of the body during ironing.

• Generally foreign bodies passes through the gastro intestinal tract within 1 week, but might get stuck especially when sharp.

• Earliest symptom is dysphagia.

• An ingestion of such an instrument is extremely rare i.e. 0.12/100,000 root canal treatments.

A case of swallowed Dental Prosthesis

• Plain abdominal radiograph

• The Endoscopic view shows the extraction from jejunum to the mouth, here the image shows that foreign body is at the esophagus.

Extracted Prosthesis• The prosthesis was a successfully managed

endoscopically.

• Observe at the right of • the dental bridge has a sharp edge.

Acute Hypoglycemia

Causes : Overdose of insulin Prevented from eatingat expected time

• MANAGEMENT:• Glucose tablets/powder• If unconscious give• 50ml 50% glucose IVSC glucagon 1mg

The Diabetic Patient Hyperglycemia Hypoglycemia

Slow onset Rapid onset

Dry skin & mouth Moist skin

Pulse slow & weak Pulse full & rapid

Drowsiness/disorientation Irritability

Rare More common

more Severe Less Severe

Difficult to be managed Easy to be managed

THYROID CRISIS (STORM)Sudden, Severe Exacerbation of Hyperthyroidism

• Precipitating Factors:• Infection

• Surgery

• Trauma

Pregnancy

• Other Physiologic or Emotional Stress

Manifestations:•

• Hyperpyrexia (Fever)

• Tachycardia

• Agitation

• Palpitation

• Nausia, Vomiting

• Abdominal pain

• Loss of• Consciousness• (Partial or Complete)

Management• Terminate all dental ttt• • Summon medical assist• • Administer O2• • Monitor VS• • Initiate BLS, if necessary• • Start IV line & Fluids• • Transport to ER Care

STEROID CRISISCirculatory Collapse

The Pt ProblemAdrenocortical Insufficiency:Primary(Addison`s Disease);RareSecondary(Exogenous);more common (20mgcortisoldaily/2weeks/year)

• CAUSES: Stress Conditions• GA• Surgical/Other trauma• Infection• Other stress• SIGNS & SYMPTOMS• Pallor• Weakness• Nausea• Rapid, weak or• impalpable pulse• Loss of consciousness• Rapidly falling BP

• Steroid Crisis Management• Lay flat and raise legs• Hydrocortisone 200mg i.v.• Give oxygen• Monitor VS• Start BLS if necessary• Consider other possible reasons for loss of• consciousness• Ambulance & transfer to hospital

ASTHMA

• Causes• Anxiety• Infection or exposure to• specific allergen• Loss or forgetting to bring• Salbutamol inhaler

Signs & Symptoms• Breathlessness• Expiratory wheezing may be• disguised as shallow breathing• Rapid pulse over 110• Accessory muscles of• respiration brought into use• Cyanosis of mucous membrane• & nail beds• Mental confusion

Management•

• Reassure the patient• DO NOT lay the patient flat• Give the anti asthmatic drug• normally used• Give oxygen• Give Adrenaline• Hydrocortisone 200 mg i.v.• Monitor VS• If no response to Salbutamol 500mcg i.m/s.c., CALL AN• AMBULANCE

Angina• Signs & Symptoms• Acute chest pain which may• radiate to left arm or shoulder• Relieved by anti anginal druge.g• .GTN 0.5mg sublingually• Aspirin 300mg• If symptoms do not resolve• rapidly with administration of• GTN, consider it likely that the• patient has suffered an MI

Myocardial InfarctionSigns & Symptoms• Severe, crushing retro-• sternal pain• Feeling of impending death• Weak or irregular pulse• Pain may radiate to left• shoulder, arm or jaw• Shock, loss of consciousness• Vomiting

Management• Place patient in a comfortable position• allowing easy breathing• Send for an ambulance• Give 50/50 Nitrous Oxide/Oxygen or Oxygenonly• Aspirin 300mg• Good pain control• Constant reassurance

Cardiac Arrest• Causes

• Myocardial Infarction• Hypoxia• Anaesthetic overdose• Anaphylaxis• Severe hypotension

Signs, Symptoms & Management•

• Loss of consciousness

• Absence of arterial pulse

summon help َ

• Patient on flat, firm surface

• CLEAR AIRWAY (keep patent)• Start CPR• Defibrillation• Transfer patient to hospital

• Chain of Survival

Stroke (CVA)• Signs ,Symptoms & management• Severe Headache• Weakness or Paralysis of arms or legs• of one side• Unilateral Facial muscle Paralysis• Difficulty or inability to Speak• Partial or Total Loss of consciousness• Patient is very anxious, needs• reassurance and transfer to hospital• immediately, BLS, Supine Position• BUT Head slightly Elevated

CONVULSIONS (Epilepsy)Grand mal, Petit mal (blank stare)

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

Convulsion•Signs & symptoms

•Grand mal

•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

Management• 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 home

Status Epilepticus

• 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

The Recovery Position

Emergency Kit• Telephone • Oxygen cylinder• • Laerdal pocket• mask/Ambubag for hand• ventilation• • Disposable airway• (Sizes1-4) Guedel• • Disposable syringes• (2,5,50 ml)

• Disposable needles (23g)• • Tourniquet• • Cannulae (20g)• • Portable suction• equipment

•• Sphygmomanometer/• automatic BP machine• • Pulse oximeter

• Adrenaline 1:1000, 0.5 ml ampoules• Glyceryl trinitrate 500 mcg spray• Aspirin 300 mg• Hydrocortisone 100mg vials• Chlorpheniramine 10 mg• Salbutamol 100 mcg (metered inhaler)• Morphine sulphate tablets 10 mg• Midazolam 10 mg• Glucagon 1 mg ampoules• Glucose powder or dextrose injection 50%

Be Prepared • Adequate training

• Protocols• Medical history• Prevention• Checks& Updating

Reference

• Medical emergency in dental office DCNA july• 199• 5 by JEFFERY D BENNETT• • Medical emergency in dental office : Malamed• 6• th• edition• • Text book of oral surgery by Bala JI

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