Emergency in Emergency in Dentistry: Part IIDentistry: Part II

HypersensitivityHypersensitivity

Chest discomfortChest discomfort

Respiratory difficultyRespiratory difficulty

Altered consciousnessAltered consciousness

Metabolic problemsMetabolic problems

Hypersensitivity Hypersensitivity ReactionsReactions

Type I:Type I:

- immediate, acute and life-

threatening

- mediated primarily by IgE

- previous exposure history

Hypersensitivity Hypersensitivity ReactionsReactions

Skin signs:Skin signs:

- erythema, urticaria, pruritis, angioedema

Respiratory tract signs:Respiratory tract signs:

- wheezing, mild dyspnea

- stridor, moderate to severe dyspnea

Hypersensitivity Hypersensitivity ReactionsReactions

ManifestationManifestation ManagementManagement

Delayed onset skin signs:Erythema, urticaria, pruritis, angioedema

1. Stop all drugs that currently use2. IM or IV Allermin/CTM or Benadr

yl p.o.3. Prescribe antihistamine

Immediate onset skin signs: Erythema, urticaria, pruritis, angioedema

1. Stop all drugs that currently use2. SC, IM or IV Epinephrine (1:1000)

0.3ml, q5m if S & S progress3. IM or IV Allermin/CTM or Benadr

yl p.o.4. Monitor vital signs5. OBS for 1 hr and prescribe antihi

stamine

ManifestationManifestation ManagementManagement

Respiratory signs (wheezing, mild dyspnea) with or without skin signs

1. Stop all drugs that currently use2. In sitting position and give O2

3. Prescribe epinephrine and antihistamine

4. Steam inhalation with bronchodilator (Atroven + Berotec or Ventolin)

Stridorous breathing (crowing sound), moderate~severe dyspnea Same as above and prepare to ER

EpinephrinEpinephrinee

Nasal cannulaNasal cannula

ManifestationManifestation ManagementManagement

AnaphylaxisAnaphylaxis (with or without skin signs): malaise, wheezing, moderate~severe dyspnea, stridor, cyanosis, total airway obstruction, nausea & vomiting, abdominal cramps, urinary incontinence, tachycardia, hypotension, cardiac dysrhythmia, cardiac arrest

1. Stop all drugs that currently use2. Put the p’t in supine position o

n back board and give O2

3. Administer epinephrine/antihistamine as above

4. Monitor vital signs and prepare for BLS

5. Steam inhalation with bronchodilator (Atroven + Berotec or Ventolin)

6. Consider if cricothyrotomy if laryngospasm cannot relieved

Differential Diagnosis of Differential Diagnosis of Acute Chest Pain: Common Acute Chest Pain: Common CausesCauses

Cardiovascular:Cardiovascular: angina pectoris, MI

Gastrointestinal:Gastrointestinal: dyspepsia (heart burn), hiatal hernia, reflux esophigitis, gastric ulcer

Musculoskeletal:Musculoskeletal: intercostal muscle spasm

Psychologic:Psychologic: hyperventilation

Differential Diagnosis of Differential Diagnosis of Acute Chest Pain: Acute Chest Pain: Uncommon CausesUncommon Causes

Cardiovascular:Cardiovascular: pericarditis, dissecting aneurysmRespiratory:Respiratory: pulmonary embolism, pleuritis, tracheobronchitis, mediastinitis, pneumothoraxGastrointestinal:Gastrointestinal: esophageal rupture, achalasiaMusculoskeletal:Musculoskeletal: chostochondritisPsychologic:Psychologic: psychogenic chest pain

Chest Discomfort:Chest Discomfort:--- AMI or angina pectoris--- AMI or angina pectoris

Pain patternPain pattern - Characteristics: squeezing, bursting, pressing, burning or choking - Location: substernum - Refer pain: L’t shoulder, arm, neck or mandible - Associated with exertion, anxiety - Relieved by vasodilator (ex. NTG) or rest - May accompanied by dyspnea, nausea& vomiting sensation, palpitation

1.1. Terminate all proceduresTerminate all procedures2.2. Semi-reclined positionSemi-reclined position3.3. Sublingual NTGSublingual NTG4.4. OO22

5.5. Check vital signsCheck vital signs

Still discomfort after Still discomfort after 3min3min

Still discomfort after Still discomfort after 3min3min

Still discomfort after Still discomfort after 3min3min

Discomfort Discomfort relievedrelieved

Give 2Give 2ndnd NTG NTG

Give 3Give 3rdrd NTG NTG

6. Assume angina pectoris was 6. Assume angina pectoris was presentpresent7. Slowly taper O7. Slowly taper O2 2 over 5minover 5min8. Modify dental treatment8. Modify dental treatment

Angina pectorisAngina pectoris

NTG NTG 0.6mg/tab0.6mg/tab

10. Assume myocardial infarction in 10. Assume myocardial infarction in progressprogress11. On IV line11. On IV line12. Prepare transport to ER12. Prepare transport to ER

MONA:MONA: MMorphine, orphine, OOxygen, xygen, NNTG, TG, AAspirinspirin

If highly suspected AMIIf highly suspected AMI

Respiratory Difficulty:Respiratory Difficulty:

AsthmaHyperventilationChronic obstructive pulmonary disease (COPD)Foreign body aspirationGastric contents aspiration

Manifestations of An Manifestations of An Acute Asthmatic Episode:Acute Asthmatic Episode:

Mild to moderateMild to moderate - wheezing - dyspnea - tachycardia - coughing - anxiety

Manifestations of An Manifestations of An Acute Asthmatic Episode:Acute Asthmatic Episode:

SevereSevere - intense dyspnea with flaring of nostrils & use of accessory muscle - cyanosis of mucous membrane & nailbeds - minimal breathing sound on auscultation - flushing - extreme anxiety - mental confusion - perspiration

1.1. Terminate all proceduresTerminate all procedures2.2. Fully sitting positionFully sitting position3.3. Bronchodilators (Atrovent/BeroteBronchodilators (Atrovent/Berote

c)c)4.4. OO22

5.5. Check vital signsCheck vital signs

Signs & symptoms Signs & symptoms continuecontinue

S & S S & S relievedrelieved

6. Give Epi 0.3ml of 1: 1,000 I6. Give Epi 0.3ml of 1: 1,000 IMM or SQor SQ7. Build up IV line7. Build up IV line8. Monitor vital signs8. Monitor vital signs

9. Prepare to ER9. Prepare to ER10. Add steroid therapy10. Add steroid therapy

6. Monitor of recovery 6. Monitor of recovery statestate7. Consult physician7. Consult physician

S & S not S & S not relievedrelieved

AsthmaAsthma

Manifestations of Manifestations of Hyperventilation Hyperventilation Syndrome:Syndrome:

NeurologicNeurologic - dizziness - tingling or numbness of fingers, toes or lips - syncope

RespiratoryRespiratory - increased rate & depth of breaths - SOB - chest pain - xerostomia

Manifestations of Manifestations of Hyperventilation Hyperventilation Syndrome:Syndrome:

CardiacCardiac - palpitations - tachycardia

MusculoskeletalMusculoskeletal - myalgia - muscle spasm - tremor - tetany

PsychologicPsychologic - extreme anxiety

Management of Management of Hyperventilation Hyperventilation Syndrome:Syndrome:

Terminate all proceduresOn fully upright positionVerbally calm patientBreath COCO22-enriched air-enriched air

Add Valium 10mg IM or IV; Dormicum Valium 10mg IM or IV; Dormicum 5mg IM or IV5mg IM or IVMonitor vital signs

AnxietyAnxiety Increased Increased cathecholamine cathecholamine

releasereleaseDecreased peripheral Decreased peripheral vascular resistancevascular resistance

Pooling of blood Pooling of blood peripheryperiphery

Compensatory mechanisms cause Compensatory mechanisms cause increased HR, feeling of warmth, increased HR, feeling of warmth,

pallor, perspiration, rapid breathingpallor, perspiration, rapid breathing

Decompensation Decompensation occuroccur

Reduced Reduced cerebral blood cerebral blood

flowflow

Lightheadness, Lightheadness, syncopesyncope

Seizure Seizure activityactivity

Reflex vagally mediated Reflex vagally mediated bradycardia, nausea, bradycardia, nausea,

weakness & hypotensionweakness & hypotension

Decreased ABPDecreased ABP

(if (if prolong)prolong)

Vasovagal syncopeVasovagal syncope

Prodrome:Prodrome:• Terminate all proceduresTerminate all procedures• Supine position with leg Supine position with leg

elevationelevation• Attempt to calm patient Attempt to calm patient • Cool towel to foreheadCool towel to forehead• Monitor vital signsMonitor vital signs

Syncopal episode:Syncopal episode:1.1. Terminate all proceduresTerminate all procedures2.2. Supine position with leg Supine position with leg

elevationelevation3.3. Check breathingCheck breathing

If absent:If absent:4. Start BLS4. Start BLS5. Prepare to ER5. Prepare to ER6. Consider other 6. Consider other cause cause

If present:If present:4. Ammonia under nose4. Ammonia under nose5. Monitor vital signs5. Monitor vital signs6. Plan anxiety control at next 6. Plan anxiety control at next visit visit

Vasovagal syncopeVasovagal syncope

Atropine 1mg/ampAtropine 1mg/ampUsed in severe Used in severe bradycardiabradycardiaNot exceed 2mgNot exceed 2mg

Manifestations of Seizure Manifestations of Seizure Attack:Attack:

Isolated, brief seizure - tonic-clonic movement of trunk & extremities - loss of consciousness - vomiting - airway obstruction - loss of urinary & anal sphincter control

Repeated or sustained seizure (status epileptics)

After seizure After seizure attackattack

1.1. Place on side and Place on side and suction airwaysuction airway

2.2. Monitor vital signsMonitor vital signs3.3. Initiate BLSInitiate BLS4.4. Administer OAdminister O22

5.5. Prepare to ERPrepare to ER

1.1. Diazepam 5mg/min IVDiazepam 5mg/min IV2.2. Dormicum 3mg/min IV oDormicum 3mg/min IV o

r IMr IM3.3. Dialantin 10~15mg/kg IVDialantin 10~15mg/kg IV

1.1. Suction airwaySuction airway2.2. Monitor vital signsMonitor vital signs3.3. Administer OAdminister O22

4.4. OBS for at least OBS for at least 1hr and consult 1hr and consult physicianphysician

Patient unconsciousPatient unconscious Patient consciousPatient consciousIf susta

ined

If susta

ined

Mild Moderate Severe

HungerNauseaMood changeWeakness

TachycardiaPerspirationPallorAnxietyBehavior change

HypotensionUnconsciousnessseizures

Manifestation of acute hypoglycemiaManifestation of acute hypoglycemia

Terminate all Terminate all proceduresprocedures

Mild S & S:Mild S & S:• Administer oral gluAdminister oral glu

cose sourcecose source• Monitor vital signsMonitor vital signs• Consult physicianConsult physician• Intake before next viIntake before next vi

sitsit

Moderate S & S:Moderate S & S:1.1. Administer oral Administer oral

glucose sourceglucose source2.2. Monitor vital signsMonitor vital signs3.3. IV D50, 50ml or IV D50, 50ml or

glucagon 1mgglucagon 1mg4.4. Consult physician Consult physician

Severe S & S:Severe S & S:1.1. IV D50, 50ml or IV D50, 50ml or

glucagon 1mgglucagon 1mg2.2. Prepare to ERPrepare to ER3.3. Monitor vital signsMonitor vital signs4.4. Give OGive O22

HypoglycemiaHypoglycemia

Manifestations of acute Manifestations of acute adrenal insufficiency:adrenal insufficiency:

WeaknessFeeling of extreme fatigueConfusionHypotensionNauseaAbdominal painMyalgiasPartial or total loss of consciousness

Management of acute Management of acute adrenal insufficiency:adrenal insufficiency:

Terminate all proceduresSupine position with leg elevationAdminister hydrocortisone 100~200mg or Decardron 5~10mgAdminister O2

Monitor vital signsSet up IV lineStart BLS if indicated

Decardron 5mgDecardron 5mg Hydrocortisone Hydrocortisone 100mg100mg

Thanks for Your Thanks for Your Attention !!!Attention !!!

ManifestationsManifestations ManagementManagement

Mild:Mild: talkativeness, anxiety, slurred talkativeness, anxiety, slurred speech, confusionspeech, confusion

Stop administer L.A.Stop administer L.A.

Monitor vital signsMonitor vital signs

OBS in office for 1 hrOBS in office for 1 hr

Moderate:Moderate: stuttering speech, nystagmu stuttering speech, nystagmus, tremors, headache, dizziness, blurred s, tremors, headache, dizziness, blurred vision, drowsinessvision, drowsiness

Stop administer L.A.Stop administer L.A.

Monitor vital signsMonitor vital signs

Place in supine positionPlace in supine position

Administer O2Administer O2

OBS in office for 1 hrOBS in office for 1 hr

Severe:Severe: seizure, cardiac dysrhythmia seizure, cardiac dysrhythmia or arrestor arrest

Place in supine positionPlace in supine position

If seizure attackIf seizure attackseizure algorism seizure algorism

Institute BLS if necessaryInstitute BLS if necessary

Prepare to ERPrepare to ER

Manifestation and management of local anesthesia toxicityManifestation and management of local anesthesia toxicity

Suggested maximum dosage of local Suggested maximum dosage of local anestheticsanesthetics

Local anestheticsLocal anesthetics Maximum No.Maximum No.

2% Lidocaine with Epinephrine2% Lidocaine with Epinephrine 1010

MepivacaineMepivacaine 66