emergency in dentistry: part ii
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Emergency in Dentistry: Part II. Hypersensitivity Chest discomfort Respiratory difficulty Altered consciousness Metabolic problems. Hypersensitivity Reactions. Type I: - immediate, acute and life- threatening - mediated primarily by IgE - PowerPoint PPT PresentationTRANSCRIPT
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