medical emergencies in dental office

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