CPR Forth Year

1. UNCONSIOUSNESS IN
DENTAL CLINIC AND
ITS MANAGMENT
Dr. Wael M. Talaat
Assistant Professor of Oral
and Maxillofacial Surgery

2. Objectives
1.
2.
3.
4.
Diagnose Unconsciousness
Know possible causes
Be familiar with BLS
Management

3. DEFINITION

UNCONSCIOUSNESS : lack of response to
sensory stimulation.

Most common emergency situation reported in
dental clinic is UNCONSCIOUSNESS

4. POSSIBLE CAUSES

1.Vasodepressor syncope

2.Drug Administration or ingestion

3.Orthostatic hypotension

4.Epilepsy

5.Hypoglycemic reaction

5. RARE CAUSES
Acute adrenal insufficency
Acute allergic reaction
Acute myocardial infarction
Cerebrovascular accident
Hyperglycaemic reaction
Hyperventilation

6. PATHOPHYSIOLOGY


1.INADEQUATE DELIVERY OF OXYGEN
TO BRAIN
OXYGEN
BRAIN ACTIVITY
UNCONSCIOUSNESS

7. 
CLINICAL EXAMPLE :
1. Hypotension

2. Acute Adrenal insufficency

3.Vasodepressor Syncope

4. Orthostatic Hypotension


8. 


2.Systemic or local metabolic
deficiencies
Chemical or metabolic derangments
Changes in Quality of blood reaching
the brain

9. CLINICAL EXAMPLE
Acute allergic Reaction
Drug Ingestion And administration

10. 3- Direct or reflex effect on nervous
system
 Due to defect in brain itself

11. 
CLINICAL EXAMPLE :
Cerebrovascular accidents

Convulsive Episodes


12. 
4.Psychic Mechanisms

Emotional disturbances are most
common cause of transient loss of
consciousness in dental clinic

13. CLINICAL EXAMPLE

Emotional disturbances

Hyperventilation

Vasodepressor syncope

14. MANAGEMENT
IMMEDIATE MANAGEMENT OF
UNCONSIOUSNESS IS PRE-DICTATED ON
TWO OBJECTIVES.
1.RECOGNITION OF UNCONSIOUSNESS
2.RECOGNITION OF POSSIBLE AIRWAY
OBSTRUCTION AND MANAGMENT

15. 1.RECOGNITION OF
UNCONSIOUSNESS

16. STEP ONE :ASSESSMENT OF
CONSIOUSNESS

LACK OF RESPONSE TO SENSORY
STIMULUS

TO CHECK WHETHER VICTIM LACK A
RESPONSE TO SENSORY STIMULATION.

17. 

GENTLY SHAKE VICTIMS SHOULDER
AND SHOUT LOUDLY
‘ARE U ALL RIGHT’

18. Pain IS ANOTHER STIMULUS

APPLICATION OF PERIPHERAL PAIN
PINCHING

EVOKES A MOTOR RESPONSE

19. STEP 2

TERMINATION OF DENTAL
PROCEDURE

20. STEP 3 SUMMONING OF
HELP

IF NO RESPONSE TO PERIPHERAL
STIMULATION

Rescuer calls for assistance immediately by
activating the dental office emergency
system

21. 
2.RECOGNITION OF POSSIBLE AIRWAY
OBSTRUCTION AND MANAGMENT

22. STEP 4
P – POSITION VICTIM

SUPINE POSITION WITH BRAIN AT THE
SAME LEVEL AS HEART AND FEET
ELEVATED SLIGHTLY

23. OBJECTIVES

SUPINE POSITION
INCREASED DELIVERY OF OXYGENATED
BLOOD TO BRAIN
O2
HEART
BRAIN
ELEVATED FEET
Increase return of blood to heart
OTHER BODY PARTS
HEART Oxygenated
blood

24. IN PREGNANT PATIENTS

TURN TO LEFT SIDE And tuck a pillow
on right side because the inferior vena cava,
which carries the blood from the lower body is
on the right side and so if she is on the left it
will not be compressed

25. STEP 5
A – Assess and open airway

Opening of airway and restoration of breathing
are most basic and important steps of BLS

26. HEAD TILT CHIN LIFT

APPLYING DOWNWARD PRESSURE ON
HEAD BY USING PALM
APPLYING UPWARD PRESSURE ON
MANDIBLE USING FINGERS

27. Head tilt–chin lift

28. JAW THRUST
RESCUERS FINGERS
ARE PLACED
BEHIND POSTERIOR
BORDER OF
MANDIBLE
DISPLACES
MANDIBLE
FORWARD
,DISLOCATING
WHILE TILTING
HEAD BACKWARD

29. 
Response to jaw thrust maneuver tells the
rescuer how deeply unconscious that victim is

30. 
A movement or audible sound is considered
positive

31. STEP 6a :assess airway patency
and (B) Breathing


Assess the patency of breathing
LOOK LISTEN AND FEEL TECHNIQUE
At chest
movements
Feel and hear air at
victims nose

32. NO RESPONSE




ADDITIONAL MANAGEMENT
1. administration of oxygen
2. monitoring of vital signs
HEART RATE – BP – RESPIRATORY
RATE

33. STEP 6b:Artifical Ventilation

VICTIM MAY RECEIVE ARTIFICAL
VENTILATION IN ONE OF THE THREE
WAYS

1.EXHALED AIR VENTILATION
2.ATMOSPHERIC AIR VENTILATION
3.O2 enriched Ventilation



34. 1.EXHALED AIR
VENTILATION

MOUTH TO
MOUTH

MOUTH TO NOSE

35. 2.ATMOSPHERIC AIR
VENTILATION

DEVICES TO DELIVER ATMOSPHERIC
OXYGEN TO LUNGS
AMBU BAG AND PULMONARY
RESUSCICATOR

36. Ventilation
Bag-Mask Ventilation
1 Person
difficult, less effective
2 Persons
easier, more effective

37. AIRWAY ADJUNCTS

AIRWAY ADJUNCTS USED

DEEPLY UNCONSCIOUS INDIVIDUALS

38. Open the Airway
Oropharyngeal Airway

39. Open the Airway
Nasopharyngeal Airway

40. Open the Airway
Endotracheal Intubation

41. Open the Airway
Laryngeal Mask Airway (LMA)

42. 3.O2 enriched Ventilation





E cylinder– 10 TO 15L for 30 minutes of
oxygen
It consists of
1.Portable E Cylinder
2.FACE mask
CAPACITY
A <B <C < D Type cylinder
are also available

43. STEP 7
C - Circulation

Monitoring heart rate and blood pressure

Sites FOR Monitoring Heart rate
1.Brachial and Radial Arteries in Arm
2.Carotid Artery in Neck

44. 
IF pulse not palpable within first 10 seconds

46. 2 mechanisms explaining the
restoration of circulation by
external cardiac massage

Cardiac pump
Thoracic
pump

47. Cardiac pump during the
cardiac massage




Blood pumping is assured by the
compression of heart between sternum
and spine
STERNUM
HEART
SPINE
Between compressions thoracic cage
is expanding and heart is filled with
blood
THORACIC CAGE
BLOOD
HEART

48. Thoracic pump at the cardiac
massage




During the chest compression blood is
directed from the pulmonary circulation
to the systemic circulation.
pulmonary circulation
systemic circulation.
blood

49. STEP 8
DEFENITIVE MANAGMENT

Which is specific for each condition

50. SUMMARY

RECOGNIZE THE PROBLEM

P - POSITION



A–B–C
D – DEFENITIVE CARE

51. Thank You

52. VARIOUS
UNCONSCIUOS
CONDITIONS

53. VASODEPRESSOR SYNCOPE

Most common cause

Young fit adult males are more prone

54. Presyncope
•
Stress 
increased release of Catecholamines

•
peripheral vascular resistance 
peripheral pooling of blood

55. blood to heart
low BP
decresed cerebral blood flow
compensatory mechanism

56. compensatory mechanism


BARORECEPTOR
REFLEXES
CONSTRICT
PERIPHERAL
BLOOD
VESSELS
CAROTID &
AORTIC REFLEX
HEART
RATE

57. compensatory mechanism
FATIGUED


REFLEX BRADYCARDIA
Heart rate less than 50 times per minute
UNCONSIOUSNESS

CARDIAC OUTPUT

58. Signs & symptoms

1.
2.
3.
4.
5.
6.
7.
Early
Feeling of warmth
Loss of colour :pale or ashen gray skin tone
Heavy perspiration
Complaints of feeling “bad” or “faint”
Nausea
Blood pressure at baseline
Tachycardia

59. 
Late
1.
Dilated pupils
Hypotension
Dizziness, weakness or nausea
Visual disturbances
Cold moist skin
Bradycardia
2.
3.
4.
5.
6.

60. Management of syncope

ASSESS CONSIOUSNESS

Activate office emergency team

P – Position patient supine with feet elevated

61. Provide definitive management
of unconsciousness

Administer oxygen
Monitor vital signs

62. Perform additional procedures
Aromatic ammonia
Atropine, if bradycardia persists
delayed recovery
POST PONE DENTAL
TREATMENT
Activate EMS

63. 2.POSTURAL HYPOTENSION
BP

64. It is a disorder of the autonomic nervous
system in which syncope occurs when the
patient assumes an upright position
Fall in systolic pressure by 20mm of Hg or
greater or a 10mm Hg or greater fall in
diastolic pressure that occurs on standing
Failure of baroreceptor reflex mechanism
POSITION
VARIATION
decrease constriction of peripheral blood vcssels
return of blood to heart

65. Management of postural
hypotension


Assess level of consciousness
Activate office emergency team

Position patient supine with feet elevated

Assess & open airway

66. 
Assess airway patency &breathing

Assess circulation

Administer oxygen

Monitor vital signs

67. 
If patient recovers consciousnessslowly
reposition the chair & discharge the patient

68. 
Delayed recovery –

summon medical assistance-
continue BLS as needed & discharge the patient

69. 3.SEIZURES

70. Definition


:A sudden
change in behavior due
to excessive electrical activity OF
the brain
Symptoms of seizures differ depending
on what part of the brain is affected.

71. TYPES
PARTIAL
SEIZURES
PRIMARILY
GENERALISED
SEIZURES

72. MANAGEMENT
OF
PARTIAL SEIZURES

73. RECOGNIZE PROBLEM
(lack of response to sensory stimulation)




DISCONTINUE DENTAL TREATMENT
ACTIVATE OFFICE EMERGENCY TEAM

74. 
P-position patient in supine
position with feet elevated
Seizure ceases
Allow patient to recover before
discharge

75. IF SEIZURE CONTINUES
(>5 min)


A
B
C
Perform BLS as Needed

76. MANAGEMENT
OF
TONIC CLONIC
SEIZURES

77. Aura

DIZZINESS
HEADACHE

UPSET
STOMACH

78. 
PRODORMAL PHASE
Recognize aura

Discontinue dental treatment

Activate office emergency team
C-D

UNUSUAL
FEELINGS
P- A –B-

79. IF SEIZURE PERSISTS FOR
MORE THAN 5 MINUTES

A-B-C-D
if AVAILABLE





administer IV
ANTICONVULSANT

80. Drug administration or ingestion

81. Drug administration or ingestion



Clinical signs and symptoms that result from
overly high blood levels of a drug in various
target organs and tissues
Drug overdose reactions or toxic reactions
Direct extension of normal pharmacologic
actions of the involved drug.

82. Clinical manifestations of local
anesthetic overdose
SIGNS
Low to moderate overdose levels
1. Confusion
2. Talkativeness
3. Apprehension
4. Excitedness
5. Slurred speech
6. Generalized stutter
7. Muscular twitching and tremor of the face

84. 9.Elevated blood pressure
10. Elevated heart rate
11.Elevated respiratory rate

85. Moderate to high blood levels
1.Generalized tonic-clonic seizure,followed
by
2.Generalized central nervous system
depression
3.Depressed blood pressure,heart rate &
respiratory rate

86. Management of a severe LA
overdose with slow or rapid onset

ASSESS CONSIOUSNESS

Activate office emergency team

P – Position patient supine with feet elevated

87. 
Administer oxygen
Monitor vital signs

88. 


administer IV ANTICONVULSANT
Activate EMS
Medical consultation

89. 5.CEREBROVASCULAR
ACCIDENT
BLOCK

90. 


Also known as Stroke
Defined as any vascular injury that reduces
cerebral blood flow to a specific region of the
brain , causing neurologic impairment
It is a focal neurologic disorder caused by
destruction of brain substance as a result of
intra-cerebral hemorrhage , thrombosis,
embolism or vascular insufficiency.

91. PATHOPHYSIOLOGY
OCCLUSIVE
BLOCKED
1.thrombosis,
2.Embolism
HAEMMORHAGIC

93. Diagnostic clues

Hypertension (blood pressure above
140/90mm Hg)
Altered consciousness
Hemiparalysis
Headache and blurred vision
Asymmetry of face and pupils of eyes

94. 
ASSESS CONSIOUSNESS

Activate office emergency team

P – A –B - C

95. 
Administer oxygen
Monitor vital signs

96. 
ESTABLISH IV ACCESS ( 5 %
DEXTROSE)

TRANSPORT TO EMERGENCY
MEDICAL CARE

97. Hyperglycemia

98. 

Elevated blood glucose level
Patients blood glucose level remain elevated
for prolonged period due to lack of insulin
BLOOD
Glucose
Insulin

99. SYMPTOMS

100. MANAGMENT

Step 1:Termination of dental therapy

Step 1a:Activation of dental office emergency
Step 2: 2:Unconscious patients should be placed
into the supine position with their legs elevated
slightly

101. supine position

102. 
Step 3:Removal of dental materials from
mouth

Step 4:A-B-C(basic life support)as needed.

103. DEFINITIVE CARE

Step 5 :D(definitive care)
Step 5a:summoning of medical assistance
Step 5b:IV infusion(if available)of 5%dextrose
and water or of normal saline

104. Dextrose

105. 
Step 5c:Administration of oxygen

. Step 5d:Transportation of the patient to the
hospital
DentalClinic


Hospital

106. Hypoglycaemia

107. 




Most dangerous complication of diabetes since
the brain is starved of glucose
Diagnosis
Deepening drowsiness
Disorientation
Excitability or aggressiveness in a diabetic
patient, especially if it is known that a meal
has been missed

108. SYMPTOMS

109. Management of hypoglycaemia

Position the patient supine with legs elevated.
Assess Airway
 Breathing
 Circulation.


Administer BLS as needed.

110. 


4 lumps of sugar
Give 150 ml glucose drink
Reassure patient

111. 



give sterile glucose IV (20ml of 20-50% of
solution)or IM glucagon 1mg
Call an ambulance
Where possible, defer further immediate dental
treatment until another day.
If unconscious,

112. Management of sudden loss of
consciousness in the absence of
an obvious diagnosis

STEP 1 :Lay the patient flat . Recovery is
almost instantaneous if the patient has simply
fainted . Call for assistance

113. 
STEP 2:Maintain the airway &give oxygen

114. 


STEP 3:Take the pulseif absent
CPR is immediately indicated.

115. 
STEP 4 :
If pulse is palpable give 4sugar lumps orally if the patient has
not completely lost consciousness
 or
 20ml of 20-50%sterile glucose IV if
unconscious.
GLUCOSE

116. 
STEP 5:
 Still no improvement –medical assistance should be
summoned.
 Give hydrocortisone sodium succinate 200mgIV
 Defer further immediate dental treatment until another day.

117. CONCLUSION

UNCONSCIUOSNESS IS THE MOST
COMMON EMERGENCY CONDITION
REPORTED IN DENTAL CLINIC

SO, as a Dentist we all should know how to
manage unconsciousness condition in the
dental clinic