Medical Emergencies In Dental Practice - By Dr Saikat Saha
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A brief and to the point management of medical emergencies in dental office for the dental surgeons. This presentation gives emphasis to the current protocol in the management of medical emergencies in dental office.
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Medical Emergencies In Dental Practice - By Dr Saikat Saha
- 1. Dr Saikat Saha Department Of Oral And Maxillofacial Surgery Kindly Note :- Through this presentation, I would like to show my tribute for the affected victims of the Nepal Earthquake 25th April 2015
- 2. MEDICAL EMERGENCIES Prevention and Management of:- Altered Consciousness, Hypersensitivity Reaction, Chest Discomfort & Respiratory Difficulty.
- 3. Act prompt during an emergency to make the best out of the worst.
- 4. Anticipate & Be Prepared
- 5. So, How Do We Anticipate ?
- 6. • Comprehensive medical history • Vigilant observation & prompt recognition of symptoms of an emergency • Basic life support • Affiliation to definitive medical care 6
- 8. COMPREHENSIVE MEDICAL HISTORY •Thorough questionnaire •Past medical history •Familial disease history •Psychological/ social status •Diet 8
- 10. ASA PHYSICAL STATUS CLASSIFICATION CLASS I: Healthy patient with no systemic disease. CLASS II: Patient with mild systemic disease with no limits on activity. CLASS III: Patient with severe systemic disease that limits activity. CLASS IV: Patient with incapacitating systemic disease that is life threatening. CLASS V: Terminal moribund patient. 10
- 11. We Need To Prepare For Management
- 15. BASIC LIFE SUPPORT Primary response to all emergencies. P-A-B-C-D •>Position •>Airway •>Breathing •>Circulation •>Definite Treatment 15
- 18. • Altered Consciousness Unconsciousness (Syncope) Postural/Orthostatic Hypotension Hypoglycemia Thyroid Gland Dysfunction Acute Adrenal Insufficiency Cerebro vascular Accident Epilepsy 18
- 19. Syncope, a transient loss of consciousness and postural tone due to reduced cerebral flow, is associated with spontaneous recovery. Unconsciousness Lack of response To Sensory Stimulation
- 21. SYNCOPE Altered Consciousness Syncope, a transient loss of consciousness and postural tone due to reduced cerebral flow, is associated with spontaneous recovery.
- 22. NEUROCARDIOGENIC SYNCOPE Neurocardiogenic Vaso-vagal Syncope Vaso--depressor syncope. Vasovagal syncope is associated with both sympathetic withdrawal (vasodilation) and increased parasympathetic activity(bradycardia) Vasodepressor syncope is associated with sympathetic withdrawal alone. Altered Consciousness
- 24. Syncope may occur suddenly Or “Presyncope symptoms” Light-headness, Dizziness, A feeling of warmth, Diaphoresis, Nausea Visual blurring Occasionally proceeding to transient blindness. Altered ConsciousnessAltered Consciousness
- 39. Delayed Recovery If recovery fail within 15 to 20 minutes. | Consider Other Cause seizure, CVA, TIA Cardiac Dysrhythmias Hypoglycemia.
- 46. Prevention: Medical history questionnaire Dialogue history Physical examination Dental therapy considerations: ASA physical status Treatment considerations II Eat normal breakfast and take usual insulin dose in the morning Avoid missing meals before and after surgery If missing meal is unavoidable, consult phycisian or ↓ insulin dose by half III Monitor blood glucose levels more frequently for several days following surgery and modify insulin accordingly Consider medical consultation IV Consult physician before treatment Altered Consciousness
- 49. TREATMENT Conscious patient Give a strong glucose drink quickly. Patient may lose consciousness any moment. Unconscious patient Three Options 1. 1mg Glucagon IM to be followed by oral glucose ASAP. 2. 50ml of 50% Glucose IV 3. 100ml of 20% Glucose IV Altered Consciousness
- 58. Thyroid gland dysfunction Altered Consciousness
- 59. 3 Thyroid Hormones • T3 • T4 • Calcitonin Regulate biochemical activity of most of the body’s tissues. Altered Consciousness
- 60. Predisposing factors: Hypothyroidism: Hyperthyroidism: Primary: Diffuse toxic goiter • Auto immune Toxic multinodular goiter • Idiopathic causes Factitious thyrotoxicosis • Postsurgical thyroidectomy T3 thyrotoxocosis • External radiation therapy Thyrotoxicosis with thyroiditis • Radioiodine therapy Hashimoto’s thyroiditis • Inherited enzymatic defect Subacute thyroiditis • Antithyroid drugs Jod – Basedow phenomenon • Lithium, phenylbutazone Malignancies TSH – producing tumors Secondary: • Pituitary tumor Hypothalamic hyperthyroidism • Infiltrative disease of pituitary Struma ovarii with hyperthyroidism Altered Consciousness
- 61. Prevention: Medical history questionnaire Dialogue history Dental therapy considerations Altered Consciousness Thyroid Gland Functioning Dental Treatment Protocol Euthyroid Can be managed normally Hypothyroid Avoidance of CNS depressants (opiods, sedative hypnotics) Hyperthyroid Avoid Atropine Vasoconstrictors, least concentrated solution is preferred 1:200,000, Smallest effective volume of anesthetic and vasodepressor, Aspiration prior to every injection Evaluation of cardio vascular disease
- 62. Clinical manifestations Hypothyroidism: Symptoms Signs Paresthesias Loss of energy Intolerance to cold Muscular weakness Pain in muscles and joints Inability to concentrate Drowsiness Constipation Forgetfulness Depressed auditory acuity Emotional instability Headaches Dysarthria Pseudo-myotonic reflexes Change in menstrual pattern Hypothermia Dry, scaly skin Puffy eyelids Hoarse voice Weight gain Dependent edema Sparse axillary and pubic hair Pallor Thinning eyebrows Yellow skin Loss of scalp hair Abdominal distension Goiter Decreased sweating Altered Consciousness
- 63. Pathophysiology: Hypothyroidism: Insufficient levels of thyroid hormones Body functions slow down Infiltration of mucopolysaccharides and mucoproteins in skin Hard nonpitting mucinous edema – myxedema Cardiac enlargement, pericardial and pleural effusions Cardiovascular and respiratory difficulties End point is myxedema coma- loss of consciousness due to hypothermia, hypoglycemia and CO2 retention Altered Consciousness
- 64. Pathophysiology of Thyrotoxicosis: Thyroid hormones ↑ body’s energy consumption and BMR Fatigue &weight loss Direct actions on myocardium - ↑ HR, ↑ myocardial irritability ↑ cardiac work load Palpitations, dyspnea, chest pain ↑ incidence of angina pectoris and heart failure ↑ thyroid hormones also affects liver function End point – thyroid storm and crisis Altered Consciousness
- 65. Management: P – Position , supine position with feet elevated D – Definitive management – activate EMS 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 Altered Consciousness
- 68. It is dangerous…. PREVENT IT. History, is important Dose… length of use… Pre-treatment double the dose… Altered Consciousness
- 69. S&S All features of SHOCK Extremely difficult to reverse Flat with feet up 200 mg Hydrocortisone IV Oxygen Ambulance Hospital Altered Consciousness
- 71. 2. Anaphylaxis
- 72. ANAPHYLACTIC REACTION Allergen Mast cell degranulation Histamine release 1.Vasodilatation & Increased capillary Permeability. Red urticarial rash Oedema Hypotension 2. Bronchospasm • Facial flushing/ itching/ paraesthesia • Facial oedema/ urticaria • Wheezing • LOC • SHOCK Acute multisystem allergic reaction involving skin, airway, vascular and GI System
- 73. PREVENT • Always take a thorough allergy history esp. Penicillin • Do not risk exposing a patient to a possible allergen. Believe your patient • Have an up to date EMERGENCY TROLLY in your clinic
- 74. MANAGEMENT • Stop treatment • Lie pt. flat with legs raised • Give oxygen and if necessary, assisted ventilation • Call ambulance • ASSESS Carefully for 10-30 secs If there is hypotension, airway oedema or bronchospasm – ADRENALINE 1:1000 1ml IM * Repeat 0.5-1ml every 5-15 minutes till there is response
- 75. After ADRENALINE • 10-20mg Chlorpheniramine IV • (diluted in syringe with 10ml blood) • 200mg HYDROCORTISONE IV (To prevent relapse) • IV Fluid (Normal Saline) 1L JET • HOSPITALISE • Ranitidine
- 76. If only allergic features present as skin rash and mild swelling, it may be appropriate to give :- Chlorpheniramine and Hydrocortisone only at the initial stage. If the patient deteriorates Adrenaline will be needed. Contact hospital anyway and make a note of the time of contact.
- 77. MONITOR Continue monitoring the patient till hospital doctors take over The team must be ready to provide CPR as a Cardiac arrest may be precipitated Keep all vials and cartons of medications
- 78. YOU Need • To provide C P R • To do Venepuncture (well) • To Have Oxygen available • To Have ADRENALINE, CHLORPHENIRAMINE and HYDROCORTISONE handy • To Call for help in time • To Keep good evidential record
- 85. ANGINA / MI Atheromatous narrowing of coronary arteries > Reduced Oxygen supply + Exercise/Anxiety/Pain/Cold/Lying Flat > Increased Oxygen demand =Ischaemic pain +/- Ischaemic damage
- 86. Nitrogyycerine
- 88. PREDICT AGE: Cumulative effect SEX: M>F; RACE: Subcontinent CIGARETTE SMOKING DIABETES, RENAL, CHOLESTEROL, OBESITY HYPERTENSION FAMILY H/O: Cardiac death of 1st relative <50
- 89. PREVENT • Preferably no procedure within 6months of an MI • DO NOT STOP ASPIRIN • Prophylactic GTN spray • DO NOT LIE FLAT • RELAX, REASSURE and sometimes mild anxiolysis, the night before • If there is H/O recent MI or unstable angina consider referring to hospital practitioner
- 104. C/O ACUTE CHEST PAIN Severe crushing retrosternal pain Radiation Pallor, Sweating, Dilated pupil Breathlessness Nausea Vomiting Loss of consciousness Weak/irregular pulse Hypotension R E L A X GTN 3 minutes HELP! Do not lie flat! OXYGEN Nitrous Oxide Aspirin 150-300mg Get ready for CPR
- 105. T H E N ? ECG Cardiac Enzymes Myoglobin (2hrs) Troponin T (6hrs) IV Cannula IV Opiate Defibrilate. THROMBOLYSIS Primary Interventional Cardiology
- 106. Tasks Identify who is at risk and when its going wrong Do not be nervous provide C P R Oxygen available Have GTN spray/tablets handy Call for help in time
- 107. EPILEPTIC FIT • Chaotic and uncontrolled neuronal activity • Congenital/ trauma/ stroke/ tumour/ infection • Many types • Grand mal
- 108. • Full blown fit • Normally rapidly self limiting • Prolonged fitting > enormous metabolic demand on brain > brain damage
- 109. • When was the last fit ? • Are the drugs being taken regularly ? • Hyperventilation due to dental fear • Flashing light from dental unit
- 110. DIAGNOSIS • Aura • Vacant/ distant/ withdrawn • Usually the patient knows • Tonic phase • Clonic phase • Flaccid phase
- 111. STATUS EPILEPTICUS TONIC > CLONIC > TONIC Usually Lasts Upto 2 mins Look For Other causes ????
- 112. TREATMENT • Relax • Stop • Remove • Floor • Airway * • Help • Diazepam • Oxygen
- 113. Administration of the diazepam • Oral !!! • IM !!! • IV ? Per Rectal Route Is The Most Recommended
- 114. Dose ? • Up to 20mg • Small increments • If you keep Diazepam you must keep Flumazenil
- 115. Remember • History • Medicines • Escort • Never a day case for GA Never let an epileptic who had just recovered go home without involving a medical checkup
- 117. AIRWAY OBSTRUCTION (CHOKING) • Kills a patient very fast • 2mins = LOC • 4mins = Irreversible brain damage • Foreign body • Inhaled blood or secretions • Tongue in unconscious patient. • Airway oedema in anaphylaxis Airway Obstruction
- 118. PREVENT • Rubber dam • Suction • Throat pack • Recovery position in the unconscious
- 120. Diagnosis • Conscious patient would struggle violently with acute airway obstruction • STRIDOR • Unconscious or sedated patient !!! Watch for increasing pulse and respiratory rates and cyanosis
- 121. Universal Sign Of Choking
- 122. REMEMBER Gradual/progressive airway obstruction in the unconscious, sedated or the very-ill will lead to cardiac arrest !
- 123. TREATMENT Conscious Clear mouth Suction Back blows Heimlich’s manoeuvre CRICOTHYROIDOTOMY Unconscious Head down Head tilt/jaw thrust Sweep mouth Suction Ventilate to see if lungs inflate BLS/ Intubate ?/ Cricothyroidotomy/ Tracheotomy
- 124. Once airway is established • Supplementary oxygen • Hospital • Spl. Care situations
- 125. Hyperventilation
- 134. 10 mg Diazepam IV / 3-5 mg Midazolam If no IV access them IM An oral dose of 10 to 15 mg diazepam usually terminates hyperventilation within 30 minutes Medications Usually Not Required
- 136. Asthmatic Crisis
- 138. Predisposing factors for asthma
- 144. •Anxiety/stress can aggravate; •Sprayed and volatile agents can do the same; •Asthmatics are Atopic (easy allergy to too many things); •Avoid GA and don’t even think of Sedation.
- 147. Breathlessness, inability to talk, Expiratory wheeze, Rapid pulse .... progress to bradycardia Accessory muscles of respiration, Cyanosis Status asthmaticus
- 148. •Reassure •Do not lay patient flat •Give patient’s own inhaler •Hydrocortisone 200mg IV •Oxygen •Salbutamol 250mc.g slow IV •Adrenaline as anaphylaxis •Ambulance > Hospital
- 150. REFERENCES • Malamed SF. Medical Emergencies in the Dental Practice. 7th ed. Baltimore: Elsevier; 2007 • Limmer D, O’Keefe M. Emergency Care. 10th ed. St.Louis: Macmillan Co; 2010 • Malik NA. Textbook of Oral & Maxillofacial Surgery. 2nd ed. New Delhi: Jaypee Brothers Pub; 2008 150
- 151. • Haas DA. Management of Medical Emergencies in the Dental Office: Conditions in Each Country, the Extent of Treatment by the Dentist. J Anaesth Prog 2006;53(2):20-24 • Geller S, Malamed SF. Knowing Your Patient. J Am Dent Assoc 2010;104:3S-7S 151