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Medical emrgencies in dental practice

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  • 1. Medical Emergencies in Dental Practice Prepared by: Dr . Aia Al-Marsumy
  • 2. What is an Emergency situations? areEmergency SituationsCommon  Fainting (Vasovagal Syncope )  Diabetic Coma  Anaphylactic Shock  Epileptic Seizures  Cardiovascular Collapse (CVC)  Thyroid Crises  Adrenal Crises  Asthmatic Attack  Stroke (Cerebro-vascular Accident, CVA
  • 3. emergencies:ofPresentationClinical - Sudden loss of consciousness - Chest pain & dyspnea - Convulsions (fits)
  • 4. Basic Emergency Procedures -Monitor BP and pulse Clear, secure & maintain Airway cardiopulmonary resuscitation intravenous cannulation ↓ Basic Life Support (BLS) A- Airway B- Breathing C- Circulation
  • 5. Collapse • shock • Steroid crisis • Myocardial Infarction • Cardiac Arrest • CVA
  • 6. Acute Chest Pain or Difficulty of Breathing Angina Myocardial Infarction Asthma Anaphylactic Shock
  • 7. Convulsions Epilepsy Any other cause of loss of consciousness including fainting
  • 8. Fainting •Predisposing factors: Stress Conditions Anxiety Pain Injection Fatigue Hunger
  • 9. Pathophysiology Stress ↓ Release of catecholamine ↓ Changes in tissue blood perfusion; decreased peripheral vascular resistance, increased blood flow to tissues ↓ leads to pooling of blood in tissue ↓ fainting
  • 10. Mechanism • Signs & Symptoms Premonitory dizziness, weakness & nausea Pale, cold moist skin Pulse initially
  • 11. Management •Lay flat & lift legs •Loosen tight clothing around neck »Give sweetened drink on regaining consciousness •Prolonged fainting, atropine 600 mcg/ml slow iv (1 ml only)
  • 12. prevention • Good history • Reassurance • General Anxiety (Stress) Reduction Protocol • Well fed prior to treatment • Glucose drink 10 mg Temazepam nocte (prior to appt) & 1hour before treatment • Delay the procedure
  • 13. Anaphylactic shock • Drugs e.g. penicillin • Insect stings • Foods, nuts, shellfish, materials Quicker onset the more severe the reaction • Widespread vasodilatation & increase in capillary permeability, potentially fatal • Hypotension
  • 14. HypersensitivityType I - Immediate - IgE mediated - Anaphylaxis - Urticaria - Angio-oedema - Allergic Asthma - Rhinitis
  • 15. Adverse Reactions • Hypersensitivity
  • 16. • Angio-oedema
  • 17. Anaphylaxis • • Signs & Symptoms variable Rapid weak or impalpable pulse • Facial flushing, itching, tingling, cold extremities • Bronchospasm (wheezing) • Loss of consciousness Pallor going on to cyanosis Cold, clammy skin Facial oedema & sometimes urticaria Deep fall in BP
  • 18. Management of Anaphylaxis •Lay flat with raised legs • •Give Adrenaline (1:1000) 0.3-0.5 ml SC or IM • •Hydrocortisone 200 mg i.v. • •Chlorpheniramine 10-20 mg slow i.v. • •Give oxygen 6L/min & assisted ventilation • •Consider Cricothyrotomy if NO quick •improvement • •Call an ambulance
  • 19. Accidental swallowing of foreign bodies • A case of swallowed dental root canal instrument Esophagogastroduodenoscopy •needle-like foreign body sticking deep in the duodenal wall
  • 20. • the object was removed by forceful extraction with a rat tooth forceps and identified as a dental root canal instrument, distinctly changed by gastric acid. Extracted instrument Original instrument
  • 21. • The patient then remembered that the pain was started after a dental root canal treatment under local anesthetics. • The pain was probably due to the irritation of the duodenal wall by needle while moving the upper part of the body during ironing. • Generally foreign bodies passes through the gastro intestinal tract within 1 week, but might get stuck especially when sharp. • Earliest symptom is dysphagia. • An ingestion of such an instrument is extremely rare i.e. 0.12/100,000 root canal treatments.
  • 22. A case of swallowed Dental Prosthesis • Plain abdominal radiograph
  • 23. • The Endoscopic view shows the extraction from jejunum to the mouth, here the image shows that foreign body is at the esophagus.
  • 24. Extracted Prosthesis • The prosthesis was a successfully managed endoscopically. • Observe at the right of • the dental bridge has a sharp edge.
  • 25. Acute Hypoglycemia :Causes Overdose of insulin Prevented from eating at expected time • MANAGEMENT: • Glucose tablets/powder • If unconscious give • 50ml 50% glucose IV SC glucagon 1mg
  • 26. The Diabetic Patient HyperglycemiaHypoglycemia Slow onsetRapid onset Dry skin & mouthMoist skin Pulse slow & weakPulse full & rapid Drowsiness/disorientationIrritability RareMore common more SevereLess Severe Difficult to be managedEasy to be managed
  • 27. THYROID CRISIS (STORM) Sudden, Severe Exacerbation of Hyperthyroidism • Precipitating Factors: • Infection • Surgery • Trauma Pregnancy • Other Physiologic or Emotional Stress
  • 28. Manifestations: • • Hyperpyrexia (Fever) • Tachycardia • Agitation • Palpitation • Nausia, Vomiting • Abdominal pain • Loss of • Consciousness • (Partial or Complete)
  • 29. Management • Terminate all dental ttt •  • Summon medical assist •  • Administer O2 •  • Monitor VS •  • Initiate BLS, if necessary •  • Start IV line & Fluids •  • Transport to ER Care
  • 30. STEROID CRISIS Circulatory Collapse The Pt Problem Adrenocortical Insufficiency:Primary(Addison`s Disease);Rare Secondary(Exogenous);more common (20mgcortisol daily/2weeks/year)
  • 31. • CAUSES: Stress Conditions • GA • Surgical/Other trauma • Infection • Other stress • SIGNS & SYMPTOMS • Pallor • Weakness • Nausea • Rapid, weak or • impalpable pulse • Loss of consciousness • Rapidly falling BP
  • 32. • Steroid Crisis Management • Lay flat and raise legs • Hydrocortisone 200mg i.v. • Give oxygen • Monitor VS • Start BLS if necessary • Consider other possible reasons for loss of • consciousness • Ambulance & transfer to hospital
  • 33. ASTHMA • Causes • Anxiety • Infection or exposure to • specific allergen • Loss or forgetting to bring • Salbutamol inhaler
  • 34. Signs & Symptoms • Breathlessness • Expiratory wheezing may be • disguised as shallow breathing • Rapid pulse over 110 • Accessory muscles of • respiration brought into use • Cyanosis of mucous membrane • & nail beds • Mental confusion
  • 35. Management • • Reassure the patient • DO NOT lay the patient flat • Give the anti asthmatic drug • normally used • Give oxygen • Give Adrenaline • Hydrocortisone 200 mg i.v. • Monitor VS • If no response to Salbutamol 500 mcg i.m/s.c., CALL AN • AMBULANCE
  • 36. Angina • Signs & Symptoms • Acute chest pain which may • radiate to left arm or shoulder • Relieved by anti anginal drug e.g • . GTN 0.5mg sublingually • Aspirin 300mg • If symptoms do not resolve • rapidly with administration of • GTN, consider it likely that the • patient has suffered an MI
  • 37. Myocardial Infarction Signs & Symptoms • Severe, crushing retro- • sternal pain • Feeling of impending death • Weak or irregular pulse • Pain may radiate to left • shoulder, arm or jaw • Shock, loss of consciousness • Vomiting
  • 38. Management • Place patient in a comfortable position • allowing easy breathing • Send for an ambulance • Give 50/50 Nitrous Oxide/Oxygen or Oxygen only • Aspirin 300mg • Good pain control • Constant reassurance
  • 39. Cardiac Arrest • Causes • Myocardial Infarction • Hypoxia • Anaesthetic overdose • Anaphylaxis • Severe hypotension
  • 40. Signs, Symptoms & Management • • Loss of consciousness • Absence of arterial pulse summon help • Patient on flat, firm surface • CLEAR AIRWAY (keep patent) • Start CPR • Defibrillation • Transfer patient to hospital
  • 41. • Chain of Survival
  • 42. Stroke (CVA) • Signs ,Symptoms & management • Severe Headache • Weakness or Paralysis of arms or legs • of one side • Unilateral Facial muscle Paralysis • Difficulty or inability to Speak • Partial or Total Loss of consciousness • Patient is very anxious, needs • reassurance and transfer to hospital • immediately, BLS, Supine Position • BUT Head slightly Elevated
  • 43. CONVULSIONS (Epilepsy) Grand mal, Petit mal (blank stare) • Predisposing factors: • Anxiety • Hunger • Menstruation • Alcohol • External stimuli, flashing lights etc • Non compliance with medication
  • 44. Convulsion •Signs & symptoms •Grand mal •Warning cry •Immediate loss of consciousness •Rigid (tonic phase) •Widespread jerking (clonic phase) •Vomiting •Flaccid after a few minutes •Consciousness is regained after a variable period •Patient may remain confused
  • 45. Management • Prevent patients from damaging themselves •  • Place in Supine position •  • Maintain patent airway •  • No medications, await recovery •  • Recovery position after fits have ceased •  • Suctioning & Monitor VS •  • Oxygen •  • Reassure on recovery •  • After fully recovered requires an escort home
  • 46. Status Epilepticus • Continuous or repeated convulsions for 15 • minutes (patient can have severe anoxia) •  • Give 10mg Midazolam IV repeat if no recovery • within 10 minutes •  • Maintain airway & give oxygen •  • Call an ambulance, transfer to hospital
  • 47. The Recovery Position
  • 48. Emergency Kit • Telephone • Oxygen cylinder •  • Laerdal pocket • mask/Ambubag for hand • ventilation •  • Disposable airway • (Sizes1-4) Guedel •  • Disposable syringes • (2,5,50 ml)
  • 49. • Disposable needles (23g) •  • Tourniquet •  • Cannulae (20g) •  • Portable suction • equipment • • Sphygmomanometer/ • automatic BP machine •  • Pulse oximeter
  • 50. • Adrenaline 1:1000, 0.5 ml ampoules • Glyceryl trinitrate 500 mcg spray • Aspirin 300 mg • Hydrocortisone 100mg vials • Chlorpheniramine 10 mg • Salbutamol 100 mcg (metered inhaler) • Morphine sulphate tablets 10 mg • Midazolam 10 mg • Glucagon 1 mg ampoules • Glucose powder or dextrose injection 50%
  • 51. Be Prepared • Adequate training • Protocols • Medical history • Prevention • Checks& Updating
  • 52. Reference • Medical emergency in dental office DCNA july • 199 • 5 by JEFFERY D BENNETT •  • Medical emergency in dental office : Malamed • 6 • th • edition •  • Text book of oral surgery by Bala JI
  • 53. THANK YOU