Medical emergencies in the dental operatory

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  • 1. MEDICAL EMERGENCIES IN THE DENTAL OFFICE: HOW TO AVOID A BAD DAY Dr.Aditi Singh P.G. 1st year Dept. Of Preventive & Pediatric Dentistry SDCH,Rishikesh
  • 2. REALITY BITES!! YOU KNOW THAT YOU ARE NOT HAVING A GOOD DAY WHEN:
  • 3. CASE # 1  A 62 y/o anxious female needs extraction of four erupted teeth. Her past medical history is positive for Type II diabetes and a history of seizures many years ago.You inject her with mandibular block. After five minutes you are summoned to the operatory by your assistant. The patient is unconscious. What could be happening and what do you do?
  • 4. THE “ARJUN - DURYODHAN” PHILOSOPHY
  • 5. PEOPLE, WE HAVE A PROBLEM
  • 6. FOUR IMPORTANT FACTORS FOR SAFELY TREATING A PATIENT AT RISK FOR A MEDICAL EMERGENCY Preparation  Diagnosis  Treatment  Prevention 
  • 7. PREPARATION  Yourself  Basic Life Support  CDE Courses  Your Staff  Basic Life Support  CDE Courses  Mock Drills
  • 8. PREPARATION  Your Office Emergency Kits  Oxygen   Access to Outside Assistance Emergency department  Local physician?? 
  • 9. DIAGNOSIS  Early diagnosis of an impending emergency is crucial  Seconds  count!!! Diagnosis  Pathophysiology  Risk factors  Precipitating factors
  • 10. TREATMENT  Early, effective treatment can limit the severity of the medical emergency   Position Medications IM  IV   Other considerations
  • 11. PREVENTION IS ALWAYS BETTER THAN CURE..
  • 12. NEVER TREAT A STRANGER
  • 13. PREVENTION Know who‟s at risk!  Medical history   History forms  Verbal history  Physical exam (vital signs)  Blood  Pulse pressure
  • 14. PATIENT EVALUATION  Past medical history  Serious illnesses  Current medical care  Hospitalizations and operations  Medications  Allergies  Paint a picture
  • 15. MEDICATIONS  Predicts diseases  Prescription  Non-prescription
  • 16. The sickest patients take the most medications
  • 17. PREVENTION Obtain appropriate consults  Alter dental treatment! 
  • 18. THE PATIENT STRESS REDUCTION THE DOCTOR
  • 19. SPECIFIC MEDICAL EMERGENCIES Airway emergencies  Cardiovascular emergencies  CNS emergencies  Other emergencies 
  • 20. AIRWAY EMERGENCIES Airway obstruction  Asthma  Hyperventilation 
  • 21. AIRWAY OBSTRUCTION-DEFINITION7  Mechanical blockage of air exchange  Tongue  Foreign body 7.Kenichi Obinata, Takafumi Satoh, Alam Mohammad Towfik and Motoyasu Nakamura:An investigation of accidental ingestion during ; dental procedures;Journal of Oral Science,53(4)495-500 2011
  • 22. AIRWAY OBSTRUCTION-DIAGNOSIS2,3 Coughing  “Crowing” sounds  Patient reaches for neck  Inability to speak  Cyanosis  Loss of consciousness  Death 
  • 23. TREATMENT6 6. Umesan et al :Prevention and management of accidental foreign body ingestion and aspiration in orthodontic practice, Therapeutics and Clinical Risk Management 2012:8;245–252
  • 24. …CONTD.1,4
  • 25. CONTD… 2,3 2.Jeffrey D.Bennet,Morton B.Rosenberg Medical Emergencies for Dentistry,ed 1,2002 Saunders
  • 26. …CONTD2,3 PEDIATRIC AIRWAY - Larynx at C2 to C4 - Narrowest portioncricoid cartilage - Shape of Epiglottis-Ω(45◦) - Rt bronchus less vertical  ADULT AIRWAY - Larynx at C4-C6 - narrowest portion-Glottis  - Shape of Epiglottis- V - Rt Bronchus more vertical
  • 27. AIRWAY OBSTRUCTION-TREATMENT1,6  Intubate/cricothyrotomy Vs Tracheostomy …. 1.European Resuscitation Council Guidelines for Resuscitation 2010
  • 28. MANAGEMENT OF HYPOCHLORITE ACCIDENT5 5. M. Hülsmann & W. Hahn:Complications during root canal irrigation–literature review and case reports,International Endodontic Journal,33;186–193, 2000
  • 29. AIRWAY OBSTRUCTION-PREVENTION10,11 Entirely preventable  Adequate protection of the oropharynx   Rubber dam  Throat screen  Ligatures around small dental objects
  • 30. ASTHMA-DEFINITION2,3  Extreme airway sensitivity and hyper-reactivity of bronchiolar smooth muscle with attendant bronchoconstriction
  • 31. ASTHMA-DIAGNOSIS2,3        Chest tightness Shortness of breath Dyspnea Wheezing Cough Hypoxia Anxiety
  • 32. ASTHMA-TREATMENT1  Mild Stop  procedure and clear mouth Position sitting upright Severe Epinephrine 0.3-0.5 mg SC/IM/IV Hydrocortisone 100 mg IM/IV Administer bronchodilating inhaler (ß2 agonist) Oxygen 1.European Resuscitation Council Guidelines for Resuscitation 2010
  • 33. ASTHMA-PREVENTION Avoid precipitating factors  Confirm that patient took asthma medications  Stress reduction  Avoid narcotics  Prophylactic bronchodilator 
  • 34. HYPERVENTILATION-DEFINITION2,3 Increased rate and/or depth of respiration  In excess of that required for metabolic rate 
  • 35. HYPERVENTILATION-RISK FACTORS2,3 Anxious patients  Patients with a history of hyperventilation  Metabolic acidosis  Hypoxia  Hypercarbia  Pain  CNS problems 
  • 36. HYPERVENTILATION-DIAGNOSIS     Patient restlessness Increased respiratory rate Increased depth of respiration Lightheadedness     Tingling in hands and feet Carpal-pedal spasm Increased anxiety Loss of consciousness
  • 37. HYPERVENTILATION-TREATMENT1     Stop procedure Clear all objects from mouth Verbally calm the patient Rebreathe CO2    Self-limiting problem Diazepam 5 mg IV or midazolam 2 mg IM/IV No O2 Paper bag Face mask Hands 1.European Resuscitation Council Guidelines for Resuscitation 2010
  • 38. HYPERVENTILATION-PREVENTION Reduce stress  Sedation 
  • 39. CARDIOVASCULAR EMERGENCIES Hypertensive crisis  Angina  Myocardial infarction 
  • 40. HYPERTENSIVE CRISIS-DEFINITION 1,4  Abnormally high blood pressure creating signs or symptoms for a patient
  • 41. HYPERTENSIVE CRISIS-RISK FACTORS 1,4 Atherosclerotic vascular disease  History of hypertension 
  • 42. HYPERTENSIVE CRISIS-PRECIPITATING FACTORS 1,4 Stress  Failure to take medication 
  • 43. HYPERTENSIVE CRISIS-DIAGNOSIS 1,4 Headache  Dizziness  Confusion  Numbness  Loss of limb function 
  • 44. HYPERTENSIVE CRISIS-TREATMENT1,4 Sit patient upright  100% O2  Call Emergency services if symptomatic  1.European Resuscitation Council Guidelines for Resuscitation 2010
  • 45. HYPERTENSIVE CRISIS-PREVENTION Check blood pressure before procedure  Assure medications  Stress reduction protocols  Watch epinephrine doses 
  • 46. DIAGNOSIS 1,4 … ANGINA     Diaphoresis Shortness of breath Nausea Unsettling to patient MYOCARDIAL INFARCTION      Angina that is prolonged or not responsive to nitroglycerin Pallor Shortness of breath Unconsciousness Weak pulse
  • 47. MANAGEMENT4 …. Semi Fowlers position Nitroglycerin 0.4 mg sublingual or spray, repeated every 5 minutes X3 oxygen 4.American heart association guidelines for CPR & ECC 2010 CPR/ Emergency dept.
  • 48. CNS EMERGENCIES Syncope  Postural hypotension  Seizure 
  • 49. SYNCOPE-DEFINITION 2,3 Transient and reversible loss of blood flow to brain causing decreased sensorium or fainting  Vasovagal syncope is the most common cause of loss of consciousness in the dental office  Generally caused by anxiety 
  • 50. SYNCOPE-PATHOPHYSIOLOGY2,3 Stress  catecholamine release blood redistribution to skeletal muscle  Lack of muscle activity  lack of cardiac return  fall in blood pressure  activation of pressure receptors to maintain blood pressure  Receptors fatigue  precipitous fall in blood pressure  loss of consciousness 
  • 51. SYNCOPE-RISK FACTORS  Patients with a history of fainting  Cause? Anxious patients  Young males (rarely children) 
  • 52. http://www.nlm.nih.gov/medlineplus/ency/article/003399.htm
  • 53. SYNCOPE-PRECIPITATING FACTORS     Stress and anxiety while immobile (as in dental chair) Prolonged standing Hot weather Hunger
  • 54. SYNCOPE-DIAGNOSIS3 Early Diagnosis  Pale  Diaphoretic  Room “feels warm”  Nausea  Pulse rapid  BP nearly normal Late Diagnosis  Loss of consciousness  Possible seizure activity  BP extremely low  Pulse extremely slow and weak
  • 55. SYNCOPE-TREATMENT3       Stop dental treatment Remove objects in mouth Trendelenburg position Raise feet Loosen restrictive clothing Supplemental oxygen
  • 56. SYNCOPE-TREATMENT3     Cool towel to forehead Monitor vital signs Ammonia vaporole At increased risk for a second faint   Call it a day Consider premedication/sedation
  • 57. SYNCOPE-PREVENTION3  Reduce stress:  Short appointments  Morning appointments  Distraction techniques  Patient education and communication  Sedation
  • 58. SYNCOPE-PREVENTION3 Treat in more supine or slight Trendelenburg position  Snack before appointment 
  • 59. POSTURAL HYPOTENSION-DEFINITION2,3 Decreased blood pressure associated with an abrupt change in patient position  Orthostatic hypotension 
  • 60. POSTURAL HYPOTENSION- PRECIPITATING FACTORS2,3 Rapid vertical change in body position in persons at risk  Dehydration  Blood loss  Allergic reactions  MI  Not induced by stress 
  • 61. POSTURAL HYPOTENSION-DIAGNOSIS2,3 Patient feels light-headed upon rapid standing  Loss of consciousness  Vital signs differ from vasovagal syncope:    Blood pressure low Pulse normal or rapid
  • 62. POSTURAL HYPOTENSION-TREATMENT2,3 Identical to treatment of vasovagal syncope  Elevate slowly when recovered  At no greater risk of repeat loss of consciousness than before episode 
  • 63. POSTURAL HYPOTENSION-PREVENTION Do not allow patients at risk to rapidly stand from the dental chair  Elevate patients slowly and in stages  Be prepared to physically support the patient if they pass out 
  • 64. SEIZURE-DEFINITION2,3  Aberrant cortical neural pathway activation  Motor activity  Sensory activity  Mixed  Status epilepticus  10-20% mortality rate
  • 65. SEIZURE-RISK FACTORS  Patients with a history of seizures  Frequency  Last seizure?  Precipitating factors (stress?)  Medications  Last time serum drug levels were checked  Changes in medications since last check
  • 66. SEIZURE-PRECIPITATING FACTORS Failure to comply with medications  Stress  Other emergency conditions 
  • 67. SEIZURE-DIAGNOSIS      Prodromal phase with personality changes Aura, depends on the location of the initiating seizure focus Loss of consciousness Ictal phase (tonic-clonic phase) Post-ictal phase
  • 68. SEIZURE-TREATMENT1 Stop dental treatment, all objects out of mouth  Remove dangerous items from around patient  Gently restrain and protect patient during ictal phase  NO tongue blades  1.European Resuscitation Council Guidelines for Resuscitation 2010
  • 69. SEIZURE-TREATMENT1 Supportive therapy during post-ictal phase  Maintain airway  Oxygen  Monitor vital signs  Call emergency dept., especially if seizure continues or repeats  Possible valium 5-10 mg IV or midazolam 2-4 mg IV/IM if seizure continues or repeats  1.European Resuscitation Council Guidelines for Resuscitation 2010
  • 70. SEIZURE-PREVENTION Confirm that patient has taken antiseizure medications on day of procedure  Limit stress  Sedation   Benzodiazepines  Barbiturates
  • 71. OTHER EMERGENCIES Allergic reactions  Hypoglycemia 
  • 72. OTHER EMERGENCIES Allergic reactions  Hypoglycemia 
  • 73. ALLERGIC REACTIONS-DEFINITION2,3 An immune response to an allergen  Re-exposure produces heightened reaction  May be immediate or delayed 
  • 74. ALLERGIC REACTIONS-RISK FACTORS2,3  Patients with known prior allergic reactions  Careful history  Specifics of previous reaction  Timing of the event  Treatment required Atopic patients  Patients may demonstrate cross reactivity to medications of a similar chemical structure 
  • 75. ALLERGIC REACTIONS-DIAGNOSIS2,3       Contact dermatitis Allergic rhinitis Urticaria Angioedema Bronchospasm and edema (asthma) Anaphylactic shock
  • 76. ALLERGIC REACTIONS-DIAGNOSIS
  • 77. ALLERGIC REACTIONS-DIAGNOSIS  Timing of the reaction    Immediate Delayed Extent of the reaction    Rash Swelling Respiratory compromise
  • 78. ALLERGIC REACTIONS-TREATMENT1  Delayed onset skin reaction     Stop dental treatment/medications Assess respiration Consider observation if localized If more generalized, diphenhydramine (Benadryl) 25-50 mg TID x 2 days 1.European Resuscitation Council Guidelines for Resuscitation 2010
  • 79. ALLERGIC REACTIONS-TREATMENT1  Immediate skin reaction  Stop dental treatment  Assess respiration  Diphenhydramine 25-50 mg IM/IV  Diphenhydramine 25-50 mg po TID x 2 days 1.European Resuscitation Council Guidelines for Resuscitation 2010
  • 80. ALLERGIC REACTIONS-TREATMENT1  Respiratory or cardiovascular compromise Stop treatment  emergency dept. Oxygen Basic life support as indicated Intubation/ cricothyrotomy 1.European Resuscitation Council Guidelines for Resuscitation 2010 Epinephrine 0.3-0.5 mg SC/IM/IV Bronchodilator inhaler if wheezing present Diphenhydramine 25-50 mg IM/IV Hydrocortisone 100 mg IM/IV
  • 81. ALLERGIC REACTIONS-PREVENTION Careful medical history  Don‟t use the drug  Avoid prescribing medications in the same class as those to which known allergy exists  Prophylactic antihistamines? 
  • 82. DIABETES-DEFINITION2,3  Lack of sufficient endogenous insulin to allow glucose to adequately enter cells  Quantitative  Qualitative
  • 83. HYPOGLYCEMIA
  • 84. HYPOGLYCEMIA-PRECIPITATING FACTORS Increased insulin administration  Poor glucose intake   Normal  insulin-inadequate diet Increased glucose metabolism  Stress  Infection
  • 85. HYPOGLYCEMIA-DIAGNOSIS Confusion  Abnormal behavior  Diaphoresis  Tachycardia  Anxiety  Loss of consciousness  Seizure 
  • 86. HYPOGLYCEMIA-TREATMENT1    Always treat as hypoglycemia until proven otherwise Administer glucose If conscious: Juice Cake  If unconscious: emergency dept. Epinephrine 0.3-0.5 mg SC/IM/IV D50W IV Glucagon 1 mg IM/IV  frosting 1.European Resuscitation Council Guidelines for Resuscitation 2010
  • 87. HYPOGLYCEMIA-TREATMENT1   Administer glucose Conscious patient  Oral glucose Sugar solution  Juice  Soda  Tablets   Cake frosting? 1.European Resuscitation Council Guidelines for Resuscitation 2010
  • 88. HYPOGLYCEMIA-PREVENTION      Assure appropriate food intake Request AM serum glucose level Stress reduction Have patient bring Accucheck to office Keep „em sweet
  • 89. THE EMERGENCY KIT THE KISS ….. Principle
  • 90. EMERGENCY KITS3  Commercial  Custom made Convenient Cheap Expensive Familiarity Too Comfort many items? Limited selection level with drugs 3.Stanley F Malamed Medical Emergencies in the Dental Office,ed 6 Mosby 2007
  • 91. COMMERCIAL
  • 92. CUSTOM MADE
  • 93. WHAT SHOULD YOU HAVE IN YOUR EMERGENCY KIT?3         Oxygen Epinephrine Chlorpheniramine maleate Sugar/cake frosting Ammonia inhalants Atropine Diazepam Hydrocortisone     Inhaler-Albuterol Nitrospray/nitroglyceride tablets Aspirin Paper bag 3.Stanley F Malamed Medical Emergencies in the dental office, ed 6 Mosby 2007
  • 94. CONCLUSIONS A medical emergency in the dental office can be a frightening experience for the patient as well as the doctor and staff  With proper preparation, prevention, diagnosis and treatment the risk of a disastrous outcome can be greatly reduced 
  • 95. CONCLUSIONS     Be prepared (yourself, staff, office) Obtain a thorough knowledge and understanding of your patient‟s medical conditions to determine medical risk Alter normal routine dental treatment to minimize risk Be alert to early signs and symptoms of an impending medical emergency, and institute early and rapid treatment
  • 96. ANY QUESTIONS???
  • 97. REFERENCES ..       1.European Resuscitation Council Guidelines for Resuscitation 2010 2.Jeffrey D.Bennet,Morton B.Rosenberg Medical Emergencies for Dentistry,ed 1,2002 Saunders 3.Stanley F Malamed Medical Emergencies in the Dental Office,ed 6 Mosby 2007 4.American Heart Association CPR ECC Guidelines 2010 5. M. Hülsmann & W. Hahn:Complications during root canal irrigation–literature review and case reports,International Endodontic Journal,33;186–193, 2000 6. Umesan et al :Prevention and management of accidental foreign body ingestion and aspiration in orthodontic practice, Therapeutics and Clinical Risk Management 2012:8;245–252
  • 98.       7.Kenichi Obinata, Takafumi Satoh, Alam Mohammad Towfik and Motoyasu Nakamura:An investigation of accidental ingestion during dental procedures;Journal of Oral Science,53(4)495-500; 2011 8.http://www.nlm.nih.gov/medlineplus/ency/article/003399.htm 9. Rosen‟s Emergency medicine : Concepts and Clinical practice 7ed 10.Ahmad IA. Rubber dam usage for endodontic treatment: a review. Int Endod J. 2009 Nov;42(11):963-72. 11.Anabtawi MF, Gilbert GH, Bauer MR, Reams G, Makhija SK, Benjamin PL, Williams OD. JADA Continuing Education: Rubber dam use during root canal treatment: Findings from The Dental Practice-Based Research Network. JADA. 2013 144(2): 179-186. 12. Mohammad Hoseini,Seyed Morteza Saadat Mostafavi,Navid Rezaei,Ehsan Javadzadeh Boluri: Orthodontic Wire Ingestion during Treatment: Reporting a Case and Review the Management of Foreign Body Ingestion or Aspiration:Case Rep Dent. 2013
  • 99. I’M OUTTA HERE Private practice State employee