Medical emergencies in dentisry
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Transcript of Medical emergencies in dentisry
MEDICAL EMERGENCIES IN
DENTISTRY
Presented By :- Chetan Barai v.s.p.m. dental college nagpur
INTRODUCTION
INCIDENCE
TYPES OF EMERGENCIES• PREVENTION• PREPARATION• MANAGEMENT
SUMMARY
CONCLUSION
REFERENCES
CONTENTS
INTRODUCTION
In spite of the most meticulous protocols designed to prevent
the development of life threatening situations, emergencies
still occur.
Such emergencies can occur in any environment, we as
“Dental Surgeons” should be always alert and should have a
thorough understanding about different emergency situation
which may come across during ones practice.
Incidence A survey done in the 90’s showed that, over a 10 year
period, 90% of dentists have encountered at least one medical emergencies.
TYPE OF EMERGENCYTYPE OF EMERGENCY NUMBERNUMBER PERCENTPERCENT
Altered Altered ConsciousnessConsciousness
17,78217,782 5959
CardiovascularCardiovascular 4,2804,280 1414
AllergyAllergy 2,8872,887 9.59.5
RespiratoryRespiratory 2,7182,718 99
SeizuresSeizures 1,5951,595 55
Diabetes-RelatedDiabetes-Related 999999 33
PREVENTION: Physical Evaluation
• Medical history questionnaire
• Physical examination (vital signs, visual
inspection, auscultation of heart and lungs)
• Dialogue history (recognition of anxiety)
Medical history questionnaire:
• Thorough questionnaire
• Past medical history
• Familial disease history
• Diet
Anxiety
Observation
• Increased BP & Heart rate
• Excessive sweating
• Dilated pupils
Psychological examination
Classification based clinical signs and symptoms: Unconsciousness
Vasodepressor syncope
Orthostatic hypotension
Respiratory difficulty
Airway obstruction
Hyperventilation
Asthma
Heart failure and acute pulmonary edema
Altered consciousness
Hyperglycemia and hypoglycemia
Hyperthyroidism and hypothyroidism
Cerebrovascular emergencies
Seizure disorders
Drug related emergency situations
Drug overdose reactions
Allergy
Chest painAngina pectoris
Acute myocardial infarction.
DETERMINATION OF MEDICAL RISK
Physical status classification system (1962, American
Society of Anesthesiologists)
ASA I : A patient without systemic disease, a normal
healthy patient
ASA II : A patient with mild systemic disease
ASA III : A patient with severe systemic disease
that limits activity but is not incapacitating
ASA IV : A patient with incapacitating systemic disease that
is a constant threat to life.
ASA V : A moribund patient not expected to survive 24 hrs
with or with out surgery.
ASA VI : Clinically dead patient being maintained for
harvesting organs.
ASA E : Emergency operation of any variety; E precedes the
number, indicating the patients physical status
( ASA E-III)
Unconsciousness :
Possible causes of unconsciousness Vasodepressor syncope Drug administration Orthostatic hypotension Epilepsy Hypoglycemic reaction Acute adrenaline insufficiency Acute allergic reaction Acute MI Hyperglycemic reaction Hyperventilation
Prevention Via prevention of predsposing factorsUse of psychosedative drugs
• Ingestion - Alprazolam (4mg), Diazepam (5mg)
• I.M / I.V administration – Butorphenol (1mg), Midazolam (5mg)
• Inhalation - N2O(15%) + O2(85%)
VASODEPRESSOR SYNCOPE
Most common form of emergency medical situation in
Dental office.
The terms syncope and faint commonly are used
interchangeably to describe transient loss of
consciousness caused by reversible disturbances
in cerebral function.
PREDISPOSING FACTORSPSYCHOGENIC NON PSYCHOGENIC Fright Anxiety Emotional Pain (sudden) Sight of blood, syringe etc
Erect sitting or standing posture
Missed meal (hunger) Exhaustion Poor physical condition Hot humid environment
Critical level of cerebral blood flow for maintenance of consciousness is estimated to be about 30ml/100gm/min.
normal cerebral blood flow is 50 – 55 ml/100 gm/min.
Systolic BP may descend to as low as 20 -40 mmHg
Seizures may be precipitated depending upon the brain damage.
SYNCOPE
PATHOPHYSIOLOGY
CLINICAL FEATURESPRE SYNCOPE
Feeling of warmth in neck and face
Colour changes to pale to ashen grey
Pupillary dilatation
Yawning
Cold extremities
Hypotension
Bradycardia
Loss of consciousness
Pulse becomes weak, thready, irregular.
Respiration becomes irregular, jerky, shallow, or may
entirely cease
Death like appearance of the patient
SYNCOPE
POST SYNCOPE Pallor
Nausea
Weakness
Sweating
Management Terminate all dental treatment
Supine position with legs raised
Attempt to calm the patient
Monitor vital signs
Assessment of consciousness (“shake and shout”)
Check for breathing
Positioning the patient
Ammonia Vapour
stimulationPharmacological managemnt:
25% dextroseHydrocortisoneAtropine
SHOCK
Type of shocks
1. Hypovolaemic shock
2. Cardiogenic shock
3. Septic shock
4. Anaphylactic shock
5. Neurogenic shock
A critical condition that is brought on by a sudden drop in blood flow through the body.
Shock is a major medical emergency which is common after serious injury.
Haemorrhage, severe vomiting and Diarrhoea.
Acute Myocardial infarction
Gram-positive and gram-negative bacterial infection, other organisms.
Drugs, insect stings
High cervical cord injury, severe Head injury.
Causes
Management ABC including high flow oxygen
Position patient in Trendelenburg position
Identify underlying cause
Establish haemostatis
Administration of intravascular fluids
Monitor vitals signs
Improving systemic perfusion and oxygenation
Anaphylaxis
Clinical features
Wheezing
Abdominal pain
Nausea
Urticaria
Flushing of face
It is a serious allergic reaction that is rapid in onset and may cause death.
Par aesthesia
Pallor
Rapid and weak pulse
Cyanosis
Edema of face
Management Terminate dental treatment
Maintenance of IV line
Supine position legs elevated
0.2-0.5ml of 1:1000 epinephrine IM
Followed by chlorpheniramine 10mg IV
Hydrocortisone 20mg IV
Monitor vital signs
POSTURALHYPOTENSION
Decline >20 -25 mm Hg in SBP or
a decline >10 mm Hg in DBP.
HR baseline or > 30 bpm
When moves from a supine to a
sitting or standing position
PREDISPOSING FACTORS
Ingestion of drugs
Prolonged period of recumbency
Inadequate postural reflex
Late stage pregnancy
Venous defects in the legs
Physical exhaustion and starvation
CLINICAL FEATURES Asymptomatic, BP changes without symptoms.
Symptomatic, such as dizziness and faintness
occur with BP changes.
Acute or reversible , typically caused by volume
loss or medication use.
Chronic or irreversible , caused by endocrine and
neurogenic factors.
MANAGEMENT –Positioning The unresponsive patient should be placed
into the supine position with the feet slightly elevated this position immediately enhances cerebral perfusion, and in most instances individual regains consciousness within a few seconds.
Prevalence of OH with labetalol is 1.4%.
Enalapril (5-20 mg/d) reduces OH episodes,
whereas long-acting nifedipine (30-90 mg/d)
increases episodes.
Affects ~50 million people in the US Types:
1. Primary:- Chronic high blood pressure without a source or associated
with any other disease
- Most common form of hypertension
2. Secondary:- Elevation of blood pressure associated with another
disease such as kidney disease
HYPERTENSION
Category Systolic mmHg Diastolic mmHg
Optimal < 120 < 80
Normal < 130 < 85
High Normal 130 - 139 85 - 89
Hypertension Stage I 140 - 159 90 - 99
Hypertension Stage II 160 - 179 100 - 109
Hypertension stage III ≥ 180 ≥ 110
Causes
Genetics-some people are prone to hypertension simply based off of their genetic makeup
Family History- your risk for high blood pressure/hypertension increases if it is in your family history
Environment
– Inactivity
– Stress
– Obesity
– Alcohol
– High Sodium Diet
– Tobacco Use
– Age
– Menopausal Medications
Treatments Step 1:
– Lifestyle modifications • Diet and exercise• Limit alcohol and tobacco use• Reduce stress factors
Step 2:– If lifestyle changes are not enough,
drug therapy will be introduced Step 3:
– If previous steps don’t work, drug dose or type will be changed or another drug is added
Step 4:– More medications are added until blood pressure is controlled
RESPIRATORY EMERGENCIES
36MANAGEMENT OF MEDICAL EMERGENCIES IN DENTAL
PRACTICE - 60
A clinical state of hyper reactivity of the
tracheobronchial tree, characterized by recurrent
paroxysms of dyspnea and wheezing.
In diagnosed pts, not an emergency.
Results from constriction of smooth muscles of the
tracheobronchial tree resulting from infection,
inflammation or a genetic disposition.
ASTHMA
Predisposing factors-INTRINSIC & EXTRINSIC
EXTRINSIC OR ALLERGIC ASTHMA
The allergens may be airborne – house dust, feathers, animal dander, furniture stuffing, fungal spores, or plant pollens.
Food and drugs – cow’s milk, egg, fish, chocolate, shellfish, tomatoes, penicillins, vaccines , asprin, and sulfites.
Type I hypersensitivity reaction – IgE antibodies produced in response to allergen
Approximately, 50% asthmatic children become symptomatic before reaching adulthood
INTRINSIC OR IDIOSYNCRATIC OR NON-ATOPIC ASTHMA
Usually develops in adult age > 35 years
Non allergic factors – respiratory infection, physical
exertion, environmental and air pollution, and occupational
stimuli.
Psychological and physiologic stress can also contribute to
asthmatic episodes.
Acute episodes are usually more fulminant and severe than
those of extrinsic asthma. Long-term prognosis also less
optimistic.
CAUSATIVE FACTORS
Allergy
Respiratory infection
Physical exertion
Pollution
Occupational stimuli
Pharmacologic stimuli
Psychologic factors
MANIFESTATIONS
MILD SEVERE Wheezing Dyspnoea Tachycardia Coughing Anxiety
Intense dyspnoea with flaring of nostrils
Use of accessory muscles
Cyanosis of mucous membrane & nailbed
Flushing of face & anxiety
MANAGEMENT
Episode terminates Episode continues
Continue treatment Administer O2
Injection of aqueous epinephrine
Hydrocortisone sodium succinate 100-200mg iv
HYPERVENTILATION
CLINICAL MANIFESTATIONS
Palpitations
Tachycardia
Dizziness
Light headedness
Numbness of extremities
Chest pain
Dryness of mouth
Short breath
Muscle pain and cramps
Tremors
Stiffness
Tension
Anxiety
Excessive rate and depth of respiration leading to abnormal loss of carbon dioxide from the blood primarily predisposed to anxiety.
Anxiety
Increased rate and depth of respiration
Increased O2/CO2 exchange by lungs
Excessive CO2 blow off>>paCO2 decreases
Hypocapnia= decreased HCO3 ion conc.
Increased blood pH>>RESPIRATORY
ALKALOSIS
PATHOLOGY
MANAGEMENT
Terminate dental treatment
Position-sitting
Verbally calm the patient
Carbon dioxide rich air (paper bag)
if it continues
Diazepam 10mg IM/ IV
Monitor vital signs
Continue dental treatment
AIRWAY OBSTRUCTION During dental treatment the potential is great that objects may fall into the posterior
portion of the oral cavity and subsequently into the pharynx.
PREVENTION Rubber dam
Oral packing
Chair position
Suction
Magill intubation forceps
Ligature
MANAGEMENTRECOGNITION OF THE AIRWAY OBSTRUCTION
Signs of complete airway obstruction
Inability to speak, breathe, cough
Universal sign for choking (choking sign)
Panic
Signs of partial airway obstruction
Forceful cough
Wheezing between coughs
Ability to breathe
Altered voice sounds
Possible disorientation
‘Crowing’ sound on inspiration
BASIC AIRWAY MANEUVERS
Position Head tilt- chin lift A+B Jaw thrust maneuver Artificial ventilation
ESTABLISHMENT OF EMERGENCY AIRWAY
Non invasive
Invasive
Back blows
Finger sweepChest thrustHeimlich maneuver
Manual thrusts
Non invasive
Tracheostomy
Cricothyrotomy
DIABETES MELLITUS
Serum glucose level can fall because of:
Increased administration of insulin
Decreased dietary caloric intake
Increased metabolic utilization of glucose (exercise, emotional
stress
WHIPPLE’S TRIAD:
1. Symtoms consistent with hypoglycaemia
2. Low plasma glucose concentration measured by precise method (Not with glucose monitor)
3. Relief of symptoms after plasma glucose level is raised.
Types of diabetes mellitus
Type 1-(beta cell destruction ,usually leading to absolute
insulin deficiency)
Type 2-(due to progressive insulin secretory defect on the
background of insulin resistance)
Gestational diabetes mellitus (GDM)-diabetes diagnosed
in the second or third trimester of pregnancy .
Pathophysiology of Hyperglycemia
Prolonged lack of insulin ( type1) or prolonged lack of tissue response(type2).
Blood glucose levels remains elevated for longer time because of glycogenolysis and decreased uptake by peripheral tissues.
Glucose exceeds 180mg/100ml-glucosuria
Clinical manifestations of hyperglycemia
symptoms:
Polyuria
Polydipsia
Polyphagia with weight loss
Recurrent blurred vision
pruritis
Loss of stength
Noctural enuresis
HypoglycaemiaBlood glucose level below 50 mg% usually indicates hypoglycemia in adults, less than 40mg% in children.
Clinical manifestations Rapid onset
Sweating
Tachycardia
Anxiety
Irritability
Disorientation
Nausea
MANAGEMENT
Terminate all dental treatment
Administer glucose source
monitor vital signs
If symptoms do not rapidly improve administer 30ml of
50% Dextrose solution IV
1mg glucagon IV or IM
0.5mg of 1:1000 epinephrine IM/ SC (every 15 Minutes)
THYROID GLAND DYSFUNCTION
Eye signs VON GRAEFE’S SIGN – Lid lag.
JOFFROY’S SIGN – Absence of wrinkling
of forehead on looking up.
STELLWAG’S SIGN – Decreased
frequency of blinking.
DALRIMPLE’S SIGN – Lid retraction
exposing the upper sclera.
MOBIUS SIGN – Absence of convergence.
MANAGEMENT
Euthyroid - patient with normal hormone levels can be managed normally
Hypothyroid – avoidance of CNS depressants (opiods, sedative hypnotics)
Hyperthyroid - avoidance of atropine and vasoconstrictors, least
concentrated solution is preferred 1:200,000, smallest
effective volume of anesthetic and vasodepressor, aspiration
prior to every injection
P – Position , supine position with feet elevated
D – Definitive management – activate Emergency Medical Services and if recovery
is not immediate, establish IV access
Hypothyroidism –IV doses of thyroid hormones (T3 & T4) for several days
Thyrotoxicosis –administer large doses of antithyroid drugs, additional therapy –
propranolol, glucocorticoids
Administer O2
Discharge or hospitalize the patient
SEIZURES
A seizure is defined as an episodic disturbance of movement,
feeling, or consciousness that can be caused by sudden
synchronous, inappropriate, and excessive electrical discharges
that interfere with the normal function of the brain.
The term epilepsy is defined as a disease of frequent
seizures that do not have a reversible metabolic cause
Epilepsy can be caused by either abnormal neuronal membrane
function or an alteration between the excitatory and inhibitory
neurons
Pathophysiology In epilepsy abnormal neurons
undergo spontaneous firing
Cause of abnormal firing is unclear
Firing spreads to adjacent or distant
areas of the brain
Often area of brain from which
epileptic activity arises.
MANAGEMENT OF SEIZURES
Treatment
Anti - epileptic drugs:
ABC’ (+ monitor / O2 /
large iv’s)
Start pharmacotherapy
immediately
Metabolic acidosis common
- if severe, give sodium
bicarbonate
Benzodiazepines
Phenytoin / fosphenytoin
Barbiturates
Others / new possibilities
CARDIOVASCULAR EMERGENCIES
65MANAGEMENT OF MEDICAL EMERGENCIES IN DENTAL
PRACTICE - 60
ANGINA PECTORIS
MYOCARDIAL INFARCTION
ANGINA PECTORISANGINA PECTORIS Definition- “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 (classic or exertional)
Variant (prinzmetal , vasospastic)
Unstable (crescendo, acute coronary insufficiency
Prevention includes stress reduction protocol, reassurance & psychosedation.
ANGINA PECTORIS
PREDISPOSING FACTORS
Physical activity
Hot humid environment
Cold weather
Large meals
Emotional stress
Fever, anaemia or thyrotoxicosis.
Cigarette smoking
High altitudes
CLINICAL MANIFESTATIONS
Chest pain
Radiation of pain
PREVENTION
Long acting nitrates- isosorbide dinitrate
Beta blockers- atenolol
Calcium channel blockers- verapamil, nefedepine
Nitroglycerine
Drugs
Recognize problem (chest pain – angina attack)Discontinue dental treatment
Activate office emergency teamP – Position, patient comfortably usually upright
A → B → C –Assess and perform BLS
D – definitive management
HISTORY OF ANGINA PRESENT NO HISTORY OF ANGINAAdminister vasodilator and O2 Activate EMS
Transmucosal nitroglycerine spray O2 and nitroglycerineOr sublingual nitroglycerine tablet Monitor and record
0.3 – 0.6 mg for every 5 min (3 doses)
IF PAIN RESOLVES IF PAIN DOES NOT RESOLVE continue with dental procedure summon medical care Administer aspirin
Continue to monitor and record vital signs
MANAGEMENT
MYOCARDIAL INFARCTIONMYOCARDIAL INFARCTION DEFINITION- “A clinical syndrome caused by deficient
coronary arterial blood supply resulting in ischaemia to a region of the myocardium and causing cellular death and necrosis.”
Predisposing Factors:Atherosclerosis and coronary artery diseaseCoronary thrombosis, occlusion and spasmMales5th and 6th decades of lifeUndue stress
MANAGEMENTMANAGEMENT Protocol common for both ACS outcomes
PORTABLE AUTOMATIC PORTABLE AUTOMATIC EXTERNAL EXTERNAL DEFIBRILLATOR (AED)DEFIBRILLATOR (AED)
Immediate recognition of cardiac arrest and activation of the
emergency response system.
Early CPR with an emphasis on chest compressions
Rapid defibrillation
Effective advanced life support
Integrated post-cardiac arrest care.
DRUG DRUG RELATED RELATED
EMERGENCIESEMERGENCIES73MANAGEMENT OF MEDICAL
EMERGENCIES IN DENTAL PRACTICE - 60
CLINICAL MANIFESTATIONSCLINICAL MANIFESTATIONS Confusion, blurred speech
Muscular twitching, facial tremor
Headache, tinnitus
Drowsiness, disorientation
Elevated BP,HR,RR
If uncontrolled, generalized tonic
clonic seizures.
MANAGEMENTMANAGEMENT Termination of the dental procedure
Positioning the patient comfortably
Reassurance of the patient
Basic life support ( BLS) as needed
Definitive care
Administration of O2
Monitoring of vital signs ( Blood pressure, heart rate and respiratory rate)
Administration of an anticonvulsant drug, if needed : Diazepam or midazolam
Gingivitis :- 91% Anaemia :- 82%Taste Alteration :-66%Halitosis :-52%Xerostomia :-48%
Morning Sickness :-48% Burning Sensation :-42% Pigmentation :-34% Tongue Changes :-17% Angular Cheilitis :-8%
Oral FindingsManagement in Pregnancy
Preventive Program
General Guidelines For Management
An accurate History
Preventive Oral Hygiene Measures
Short Appointment in Patients convenience
Treatment Timing
Drug Administration During Pregnancy
FUNCTIONAL EMERGENCIES
NEEDLE STICK NEEDLE STICK INJURYINJURY
Stop procedure immediately. Wash skin with disinfectant. Treat with running water and
encourage bleeding Dry area and cover with
antiseptic dressing Recording medical history vital
in case of an exposed needle situation.
Seek antidotal vaccination or treatment if necessary.
Invariably associated with faulty
techniques such as:
bending the needle while
administering LA
inserting the needle up to the
hub
directing the needle against
resistance
May also occur if pt jerks head
during administration.
Most commonly with IANB.
Elasticity of soft tissue produces
rebound, burying the fragment within.
NEEDLE NEEDLE BREAKAGEBREAKAGE
MANAGEMENTMANAGEMENT Inform pt of the occurrence, tell him/her to remain calm,
keep mouth open and refrain from any jaw movements.
Retrieve the fragment, if visible, with a haemostat.
A buried fragment needs to be located ASAP using radiographs or CT scans & retrieved surgically.
Basic Life Support
Primary response to all emergencies
P-A-B-C-D
Position >Airway >Breathing >Circulation
>Defebrilation
P-A-B-C-D MODIFIED TO
P-C-A-B-D
15 compressions – 2 rescue breaths
4 cycles – 1 minute
Cardio Pulmonary ResuscitationCPR
Steps in CPR Recognize cardiac arrest
Check for unresponsiveness
SHAKE AND SHOUT
CPRCardio Pulmonary Resuscitation
ABC of CPR A – Airway
B- Breathing
C- Circulation
Airway
Head tilt / chin lift
Sniffing morning air position Jaw thrust method
Check for Carotid pulse
Breathing Look for rise and fall of chest
Listen and feel for movement of airBreathing
Mouth to mouth
Mouth to nose
Endotracheal intubation
Oesophageal obturator airway
Position of hands to administer chest compression
OFFICE EMERGENCY KIT Oxygen, Ambu bag with mask Suction Syringes and needles Tourniquets Cricothyrotomy equipment Airways, laryngoscope
Epinephrine Diphenhydramine Diazepam Hydrocortisone Morphine Dextrose 50%
FUTURE OF CPR“DON’T WORRY ABOUT BEING
SCRUTINIZED FOR DOING IT
RIGHT-DOING SOMETHING IS
BETTER THAN DOING NOTHING”
CONCLUSION Commonly seen signs and symptoms include alterations of
consciousness, respiratory distress, seizures, drug related
emergencies and chest pain.
In each situation a successful outcome depends on our
adherence to defined treatment protocol.
Once such steps are employed successfully additional
(secondary) steps can lead us towards a more definitive
diagnosis which can help correct the problem.
REFERENCES
1. Medical emergencies in dental office- Stanley F. Malamed
2. Medicine 3rd Edition- K.George Mathew
3. Contemporary oral and maxillofacial surgery- Peterson
5. Principles and practice of medicine-Davidson