Unconsciousness

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Unconsciousness

  1. 1. UNCONSCIOUSNESS rd 3 Lec. 18 Mar. 2009 Dr. Adel I. Abdelhady BDS, MsC, (Tanta, Egypt.), PhD (Egypt, USA) Oral and maxillofacial Surgery Dept. College of Dentistry, King Faisal university, KSA
  2. 2. UNCONSCIOUSNESS GENERAL CONSIDERATION General Causes of unconsciousness Predesposing factors in dental settings General Prevention: Clinical manifestation: Management of unconsciousness VASODEPRESSOR SYNCOPE Postural hypotension ACUTE ADRENAL INSUFFICIENCY Differential diagnosis
  3. 3. GENERAL CONSIDERATION Definition  Consciousness….awareness of surroundings… respond to questions & commands  Unconsciousness is a lack of response to sensory stimulation  ie Unconscious patient is a patient : incapable of responding to sensory stimuli with loss of the protective mechanisms especially which maintain patent airway  Syncope……….sudden…transient loss of consc  coma …prolonged loss of consc,,,as.deep sleep….. can not be aroused by simple measurements. 
  4. 4. GENERAL CONSIDERATIONS     Terms Confusion intermingling of ideas Delirium illusions, delusions Dizziness a disturbed sense of relationship to space unsteadiness-         Causes drug overdose…..alcohol…… local anesthesia, sedat… Hyperventilation Hypoglycemia Hyperglycemia Hypothyroidism Hyperthyroidism cerebr vasc
  5. 5. Predisposing Factors      These factors includes: 1-Stress ( Vasodepressor syncope) 2- Impaired physical status( ASA III or IV) 3- Administration or ingestion of drugs( LA, analgesics, antianxiety agents, CNS depressant leading to alterations in consciousness When a patient with impaired physical status is exposed to undue physiologic or psychological stress, the chance are even greater that this patient may react adversely to the situation.
  6. 6.  Individuals with underlying cardiovascular disease may respond to the stress with sudden death secondary to cardiac  dysrhythmias, which are precipitated by the same physiologic stress that can cause vasodepressor syncope in healthy individual
  7. 7. ASA I Healthy, normal patient Physiologically able to tolerate the stress Without psychological problems No treatment modifications are indicated
  8. 8. ASA II Mild systemic disease Can perform normal activity without experiencing distress Healthy patient with more extreme anxiety May need modification in treatment
  9. 9. ASA III Severe systemic disease Limited activity but not incapacitated Need stress reduction method during dental treatment May need to alter treatment
  10. 10. ASA IV Has an incapacitating disease that is life threatening Patient is in distress at rest No elective dental therapy Emergency treatment should be in hospital setting
  11. 11. ASA V Moribund patient - not expected to live 24 hours with or without operation
  12. 12. Prevention  Loss of consciousness can be prevented in many, if not most, by thorough pretreatment medical and dental evaluation.  Recognition  Termination  Activate ER team  Position  A, B, C, D.
  13. 13. General Causes of unconsciousness :  1-Neurogenic & Psychogenic :  e.g. stress, injections in dental office  vasodepressor ----> syncope..  2-Vascular  3-Cardiogenic  4-Failed Oxygenation  5-Drugs  6-Endocrine
  14. 14. Predesposing factors for uncon in dental settings:  1. Stress:  2. Impaired physical status.  3. Drug : as     analgesics anti anxiety antibiotics
  15. 15.  Clinical manifestation: - Unconscious patient is:  incapable of responding to sensory stimuli.  - with Loss of protective mechanisms especially which maintain patent airway.
  16. 16. General Prevention  1. Preliminary patient evaluation to recognize fearful patients and if there is dental fear—use sedation technique.  2. Sit down dentistry:  i.e, treat patient while lies in a supine or slightly recumbent position.
  17. 17. Pathophysiology:    the most important factor in pathogeneses of unconsciousness is Hypotension. O2 deprivation: is a major pathophysiologic factor in unconsciousness ie Air way obstruction -->    permanent brain damage in 4 – 5 mint. & cardiac arrest in 5-10 mint. General , local metabolic & C.N.S. changes also occur .
  18. 18. NB  Psychic mechanisms: are the most important mechanism involved in transient loss of consciousness or syncope 
  19. 19. Inadequate Cerebral Circulation The most common mechanism of syncope is sudden decrease in the delivery of blood to the brain:  1-Dilation of peripheral arterioles  2-Failure of normal peripheral vasoconstrictor activity ( orthostatic hypotension)  3-A sharp drop in COP heart diseases  4-Constriction of cerebral vessels as carbon dioxide is lost in hyperventilation  5-Occlusion or narrowing of internal carotid or other arteries to the brain  6-Life-threatening ventricular dysrhythmias  The first four cause no harm if the patient is in supine position 
  20. 20. Recognition of Unconsciousness  Step1: Assessment of consciousness :  *Lack of response to sensory stimulation  *Loss of protective reflexes  *Inability to maintain a patent airway  Step2:Terminate dental procedure.  Step3: Summoning of help, rescuer should call for assistance immediately by activating the dental office emergency system
  21. 21.  Step4: Position victim  Strp5: Start BLS A,B,C,D Supine posit feet elevated 10-15
  22. 22. Causes of Partial Airway Obstruction Sound Probable cause Management Snoring Hypopharyngeal obstruction by the tongue Repeat head tilt, jaw thrust Gurgling Foreign bodies (blood, vomits) in airway Suction airway Wheezing Bronchial obstruction Asthma Laryngospasm Administer Bronchodilator Crowing Suction airway; positive-pressure
  23. 23. Determination of Airway Patency and Breathing Clinical Signs Diagnosis Can feel and hear air at nose and mouth and see chest and abdominal movement Can feel and hear air at nose and mouth but no chest and abdominal movement Cannot feel or hear air at mouth and nose and chest and abdominal movements heaving and erratic Cannot feel or hear air at mouth and nose and no chest and abdominal movements Airway patent ; patient breathing Management Maintain airway Airway patent ; patient breathing Maintain airway Patient attempting to breath, but airway obstruction still present Repeat head tilt, if necessary use jaw thrust technique Respiratory arrest Artificial ventilation
  24. 24.  The basic steps in the management of unconsciousness are: R.t.p.- A B C D:  -R: recognition of case  -t : terminate dental procedure -p: position,  - A: air way,  - B: breathing,  - C: circulation
  25. 25. Management of unconsciousness R-recognition of unconsciousness  ie :assessment of consciousness : You should diagnose unconsciousness by A- no response to sensory stimulation : eg. are you all right ? response to painful stimuli or B- no protective reflexes or C- inability to maintain a patent airway.  T        :Terminate dental procedure . :summoning [call] of help .
  26. 26.     P: position care : Supine position feet elevated 10-15 remove any head supports
  27. 27. Supine posit feet elevated 10-15
  28. 28. Remove any head supports
  29. 29.  A : airway open    By – head tilt technique ---- jaw thrust technique ---- head tilt- chin lift technique
  30. 30. Head tilt technique
  31. 31. Jaw thrust technique
  32. 32. Head tilt- Chin lift technique
  33. 33. Old :head tilt- neck lift technique
  34. 34. Head tilt- chin lift technique will elevate the tongue & ensure patent air way
  35. 35.  B : Breathing Care  *** do – look-listen & feel technique *** if the rescuer thinks a foreign material in the airway he should tilt the patient back       turn the head to one side remove any thing in oral Cavity by fingers or by high volume suction technique *** then Give O2 by artificial ventilation
  36. 36. look-listen & feel technique LLF
  37. 37. Remove any Thing in Oral Cavity by Fingers
  38. 38.  Methods of Artificial Ventilation      Exhaled air ventilation mouth to mouth mouth to mask atmospheric air ventilation O2 enriched ventilation
  39. 39. Exhaled Air Ventilation
  40. 40. Atmospheric air ventilation
  41. 41. O2 enriched ventilation
  42. 42. C: Circulation Care  C: circulation care monitor heart rate  blood pressure  If pulse is absent-> Activate CPR external chest compression 
  43. 43. Asses circulation feel carotid pulse
  44. 44.  D: definitive   management : depending on cause see Causes of unconsciousness
  45. 45. VASODEPRESSOR SYNCOPE  synonyms :  VASOVAGAL SYNCOPE, FAINT  Neurogenic syncope  Psychogenic syncope  Atrial bradycardia  Definition  sudden transient loss of consciousness caused by reversible disturbance in cerebral function
  46. 46.  Commonest emergency in dental off  Relatively harmless  PREDISPOSING FACTORS psychogenic factors: fright ,anxiety,  non psychogenic factors: erect ,hunger 
  47. 47. CLINICAL MANIFESTATIONS OF SYNCOPE  -usually develops rapidly  -passes in 3 phases:    pre syncope syncope post syncope
  48. 48. postsyncope Pre Syn cope syncope
  49. 49. Presyncope  Patient is erect & complains of bad feeling  Pallor  Sweating  Nausea  Blood pre ---baseline  Pulse ----- rapid  Followed by hypotension & bradycardia
  50. 50. Syncope            CNS-------loss of consc convulsion Death like appearance sweating vomiting, Blood pr decreased Pulse is slow [bradycardia] &low [thready] Breathing ---irregular Pupil -----dilates….dilates……dilates MS--------twitches, convulsions NB syncope lasts less than 15 m if longer ….
  51. 51. Post-syncope  Usually recovery is rapid  Patient ------- weakness     pallor sweating, nausea, weakness,
  52. 52. ALTERED CONSCIOUSNESS Confusion intermingling of ideas Delirium illusions ,delusions Dizziness a disturbed sense of relationship to space unsteady-------
  53. 53. Predisposing factors  Drugs alcohol; local anesth sed,  Hyperventilation  Diabetes mellitus  Thyroid gland dysfunctions
  54. 54. Prevention  Early recognition  Avoid drugs medical history  clinical exam 
  55. 55. Clinical manifestation Depend on cause  in Hyperventilation: rapid respir rate  in Hypoglycemia : cold wet skin  in Hyperglycemia : hot dry skin   in Hypothyroidism: weakness fatigue  in Hyperthyroidism : restlessness  in cerebr vasc acc: sudden loss of consc
  56. 56. Management  1-Recognize  2- terminate dental procedure  3-P-----depend on cause    supine position is accepitable……. in diabetic & thyroid dis--- upright in cerebrovasc acc---- can upright to dec bl pr  3- A,B,C  4-definitive care  m- monitor vital signs  m- manage signs & symptom  d-defin tt depend on cause
  57. 57.  Important Causes of unconsciousness :  1-Neurogenic [ Psychogenic VASODEPRESSOR SYNCOPE :  2-Vascular : postural hypotension  3-Cardiogenic  4-Failed Oxygenation  5-Drugs 6-Endocrine :ACUTE ADRENAL INSUFFICIENCY 
  58. 58. Prevention  1-avoid the predisposing factors:  2-Proper position: supine posit…… Never treat in upright posit  3-relief anxiety : by sedations 
  59. 59. Management  Pre syncope : R T  Syncope P…. A B C D : R T P…. A B C D  Post syncope : R T P…. A B C D
  60. 60. Postural hypotension  The Second common cause of uncon in dentistry  Definition : a disorder of autonomic nerv syst in which syncope occurs when the patient assumes an upright position or a drop of systolic bl pr ---20 mg or more on standing
  61. 61.  CAUSE : failure of baroreceptor reflex  PREDISPOSING FACTORS  prolonged recumbence  Inadequate postural reflexes  Drugs  Pregnancy  aging
  62. 62. Management of Postural hypotension  Step 1 :R : assessment of consciousness :  Step 2 : T : terminate dent mang & activate office emergency.  Step 3 :P: position :  Supine posit, feet elevated 10-15  Step 4 : A : airway care  : B : breathing care  : C : circulation care
  63. 63.  Step 5 :D: definitive care :position care  Monitor bl ,HR  Give O2  Step 6 :subsequent management  changes of position must be slow
  64. 64. Adrenal dysfunctions  Less seen in dentistry  Hormones------ Structure------- Dys function   Hypo function-Addison dis, ,, acute adr ins Hyperfunction--Cushing syndr,,, adr crisis
  65. 65. ACUTE ADRENAL INSUFFICIENCY causes  Lack of glucocorticoids as in  1- adrenal diseases  [ primary adrenal insufficiency ]  hage,  trauma,  infections  sudden stop of gluc c.after prol ttt  2- pituitary diseases [secondary adrenal insufficiency 
  66. 66. Clinical Manifestations  Weakness & fatigue  Anorexia & decrease weight  hypotension  hyper pigmentation
  67. 67. Hyper pigmentation
  68. 68. Management of ACUTE ADRENAL INSUFFICIENCY       General Dental considerations : consult a physician give glucocorticoids before during after stress ????????????????????
  69. 69. Manag :A- consc patient            1-R 2-T- terminate dental procedure 3-P 4- A B C 7-definitive care m- monitor vital signs m- medical assistance o- emergency O d-drugs glucocorticoids
  70. 70. Drugs : corticocorticoids
  71. 71. Manag :B- unconsc patient             1-R…. recognize unconsc 2-T …. 3-P….. 4- A B C 7-definitive care m- no time for monitor vital signs m- no time medical assistance o- emergency O d-drugs glucocorticoids e-emergency fluid therapy
  72. 72. Differential diagnosis  Causes of unconsc VASODEPRESSOR SYNCOPE Postural hypotension ACUTE ADRENAL INSUFFICIENCY
  73. 73.  CLINICAL ITEMS HELP TO ESTABLISH THE CAUSE OF UNCONSCIOUSNESS  AGE  0—14 H E  hypoglycemia  epilepsy  14—40 : S H E  Syncope psychogenic  hypoglycemia  epilepsy
  74. 74.  40---     H heart diseases : infarction, valvular les, cerebrovasc acc.
  75. 75. Diff diag of UNCONSCIOUSNESS
  76. 76.  STRESS……….S H E psychogenic syncope  hypoglycemia  epilepsy  myocardial infarction,  cerebrovasc acc.  STRESS is absent in  Postural hypotension  Drugs  Allergic reactions  Hyperglycemia 
  77. 77.  Skin :pale & cold -------syncope  Headache ---------cereb vas acc  Chest pain------------- angina pect  Breath odour--------alcohol  Heart rate incr in hypoglyce,,hyperglyc  decr in vasodepressor  Blood pr ………  incr in cereb vas acc
  78. 78. Weakness & fatigue Anorexia & dec weight hypotension hyper pigmentation

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