medical emergency and management in dentistry

1. MEDICAL EMERGENCY IN DENTAL PRACTICE
• Presented by
• DR. Dilip Kr. Maurya
• MDS IInd year
• Dept. of Periodontology

2. Contents
• Introduction
• Incidence
• Basic steps to emergency
management
o Prevention
o Preparation
o Management
• Common medical emergencies
 Classification
 Vasovagal syncope
 Allergy
Airway obstruction
Hyperventilation
Asthma
Angina
Seizures
Orthostatic hypotension
Hypoglycemia
Acute adrenal insufficiency
Angina
Myocardial Infarction
•Conclusion
•References

3. INTRODUCTION
• Emergency is defined as a sudden, urgent, usually unforeseen occurrence requiring
immediate action.
-(Dorland’s Medical dictionary)
• Medical emergencies can happen at any time in dental practice, and a pediatric
practice is no different.
• They can happen to anyone—a patient, a doctor, a member of the office staff, or a
person who is merely accompanying a patient.
Fast TB, Martin MD, Ellis TM: Emergency preparedness: a survey of dental practitioners, J Am Dent Assoc 112:499–501, 1986

4. Incidence of emergencies in dental clinic
Mostafa Alhamad, Talib Alnahwi, Hassan Alshayeb, Ali Alzayer, Omran Aldawood, Adeeb Almarzouq, Muhammad A. Nazir J Family Community Med. 2015 Sep-Dec; 22(3): 175–179.
44.8%
21.3%
16.6%
11%
8.3%
53.1
%
Vasovagal
syncope
Allergies
Hypoglycemia
hypotension
Seizures
Heart related
0 50 100
5.5%
Foreign body
aspiration
Most common – Syncope,
Hypoglycemia, seizures
Least common – Stroke, heart
related problems etc.

5. Prevention
Preparation
Action
A ‘three-pronged approach’ that addresses prevention, preparation, and action
can help doctors and their staffs proactively manage office emergencies.
Laura M. Managing Medical Emergencies in the Office Practice Setting: A Three-Pronged Approach.

6. Laura M. Managing Medical Emergencies in the Office Practice Setting: A Three-Pronged Approach.

7. Physical Examination
Monitoring of vital signs
• Visual inspection of the patient
• Function tests as indicated
Blood
pressure
Heart rate
(pulse) and
rhythm
Respiratory
rate Height
Temperature
Weight

8. Risk Assessment
ASA PHYSICAL STATUS
Amr E. Abouleish, Marc L. Leib, J.D, Neal H. Cohen. ASA Provides Examples to Each ASA Physical Status Class. June 2015.
non-smoking, no or minimal alcohol use
current smoker, social alcohol drinker, pregnancy, obesity
(30<BMI
poorly controlled DM or HTN, COPD, morbid obesity (BMI
≥40) history (>3 months) of MI
Recent (<3 months) MI, CVA, ongoing cardiac ischemia or
severe valve dysfunction, sepsis, DIC
ruptured abdominal/thoracic aneurysm, massive trauma,
intracranial bleed with mass effect, MODS
EXAMPLES

9. Medical emergency in dental office by Stanley Malamed 7th edition

10. Preparing for Office Emergencies
• It is important that all dentists and staff members should be
master in BLS at the health care provider (HCP) level of
training.
• working knowledge of the signs, symptoms.
• course and therapy for common treatable conditions.
Personal Preparation

11. Courses
• As per recent protocols by regulatory authorities AHA, AAP ,
AAPD etc.
BLS
•Basic life support
MEDO
•Medical emergencies
in Dental office

12. MANAGEMENT DURING AN EMERGENCY
• The golden rule : P- A- B- C-D
 P- Position of the patient on the dental chair.
 A -Airway should be open and patent.
 B -Breathing should be maintained.
 C- Circulation of blood in carotid artery is assessed to see if the heart is
beating and adequately perfusing the brain.
 D-Definitive therapy, i.e. use of drugs or dialing emergency is done
depending on the physical signs and the presenting emergency situation.

13. POSITION (P)
• For a conscious patient: Whatever position is
comfortable for the patient.
• For an unconscious patient: All unconscious patients
are placed in a position to increase cerebral flow with
minimal interference with ventilation.
• Place the patient in a supine position
• Head at the same level as the body
• Feet slightly elevated (10-15 angle)

14. Airway maintenance (A)
 The anatomical factors that increases the
risk of airway obstruction in infants are:
• Smaller infant mouth, nose and air
passages
• Larger infant tongues relative to oral cavity
• Narrow trachea, glottis opening
• Narrowest cricoid cartilage ring
• Non palpable cricothyroid membrane.

15. Breathing (B)
• During the immediate assessment of breathing, it is vital to diagnose and
treat life threatening breathing problems immediately.
i. Clinical signs- Sweating, Central Cyanosis, use of the accessory muscles of
respiratory and abdominal breathing.
ii. Seeing the victim’s chest moving does not always mean that the victim is
breathing, but means that an attempt to breathe is made.
“LOOK-LISTEN-and FEEL” technique is used.
iii. Count the respiratory rate.
-increase in the breathing rate denotes illness, a warning that a patient may
deteriorate and may need medical help.

16. Circulation (C)
• Simple faints or vasovagal episodes are the most likely cause
of circulation problems in general dental practice.
i. Look at the color of the hands and fingers: Are they blue, pink,
pale or mottled?
ii. Assess the limb temp. by feeling the patient’s hand: Are they
cool or warm?
iii. Measure the capillary refill time
• Apply cutaneous pressure for 5 seconds on a fingertip held at
heart level with enough pressure to cause blanching, check the
time for refill.

17. iv. The normal refill time is less than 2 sec, increase in refill
time indicates poor peripheral perfusion.
v. Count the patient’s pulse rate.
vi. Palpation of carotid artery preferred in children and
adults, brachial pulse preferred in infants
vii. Weak pulses in a patient with a decreased conscious
level and slow capillary refill time suggest a low blood
pressure.
viii. In absence of palpable pulse, chest compression
should be started immediately.

18. Minimal Emergency drugs
Medical emergency in dental office by Stanley Malamed 7th edition
Minimal Emergency
Drugs

19. Medical emergency in dental office by Stanley Malamed 7th edition

20. Medical emergency in dental office by Stanley Malamed 7th edition

21. Medical emergency in dental office by Stanley Malamed 7th edition

22. EMERGENCY EQUIPMENTS
Critical emergency equipment
•Scalpel or cricothyrotomy Needle
•Oropharyngeal and nasopharyngeal airways
•Laryngeal mask airway
•Laryngoscope and endotracheal tubes
Secondary emergency equipment
•O2 delivery system
•Syringes
•Tourniquets
•suction and suction tips
•Automated external defibrillator
•Intubation forceps

23. American Heart Association Recommended
sequence for BLS
• Initiating chain of survival
• Chest compressions
• Airway
• Breathing
• Defibrillation

24. Chain of survival
• It provides symbol of important links of distinct steps in
emergency cadiovascular care in sequential manner.
In children, the cardiac arrest is often secondary to respiratory failure and shock

26. Common medical emergencies in dental office
Unconsiousness
Respiratory
distress
Altered
Consciousness
Seizures
Chest pain
Drug related
emergencies
Vasodepressor syncope
Orthostatic hypotension
Acute adrenal
insufficiency
Airway obstruction
Hyperventilation
Asthma(bronchospasm)
Angina pectoris
Acute myocardial
infarction
Hypoglycemia
Drug overdose
reactions
Allergy
Stanley f. Malamed. Medical emergencies in the dental office. 7th edition

27. Classification
Noncardiovascular
•Vasodepressor syncope
•Hyperventilation Seizure
•Acute adrenal insufficiency
•Thyroid storm
•Asthma (bronchospasm)
Cardiovascular
•Angina pectoris
•Acute myocardial infarction
•Acute heart failure (pulmonary
edema)
•Cerebral ischemia and infarction
•Sudden cardiac arrest

28. Non- Stress related
Noncardiovascular
•Orthostatic (postural)
hypotension
•Overdose (toxic) reaction
•Hypoglycemia
•Hyperglycemia
•Allergy
Cardiovascular
•Acute myocardial
infarction
•Sudden cardiac arrest

29. Memorise!
5 A
•Allergy
•Airway obstruction
•Adrenal insufficiency
•Angina
•Asthma
3 S
•Syncope
•Seizures
•Stroke 5 H
•Hypoglycemia
•Hyperglycemia
•Hypertensive
•Hypotension
•Hyperventilation
C T
•Cardiac Arrest
•Thyroid storm
Source-MS dental lectures
3S 5A 5H CT

30. DIABETIC EMERGENCIES
There are two types of problems associated with diabetes
while getting treatment in dental office:
Hypoglycemia or insulin shock
Diabetic comma or ketoacidosis or hyperglycemia.

31. HYPOGLYCEMIA
Signs and Symptoms:
Pallor ,sweating and tremors
Palpitation
Generalized weakness
Hunger pains
Tachycardia
Headache
Confusion
Visual and speech disturbances
Ultimately coma

32. Management:
Conscious patient 20gm of oral glucose
Unconscious patient 50cc 50% glucose IV
Adrenaline:0.5cc of 1:1000 subcutaneosly
Glucocorticoids: 100mg of hydrocortisone hemisuccinate IV
Glucagon:1-2mg IM

33. HYPERGLYCEMIA
Signs and Symptoms:
 Hypotension
 Typical acetone breath
 Rapid deep breathing
 Dry skin and dry mouth
 Enophthalmos
 Ultimately diabetic coma

34. Management:
Management of hyperglycemia is similar to hypoglycemia when an
emergency arises in dental clinic, as hypoglycemia is more life
threatening.

35. SYNCOPE

36. CVS CAUSES

38. What is shock?
It is a phenomenon marked by circulatory deficiency which
is either cardiac or vasomotor in origin exhibiting
marked hypotension.

39. SHOCK
Signs and symptoms:
 Unconsiousness
 Mucous membrane is pale
 Lips, nails & finger tips and lobules of the ear are
grayish blue
 Face is expression less with sunken eyes
 Pupils are dilated but react feebly to light
 Pulse is weak and thready
 Shallow and irregular respiration
 Temperature is subnormal

40. Treatment:
 Patient positioning
 Maintain the body heat
 Airway maintenance
 Control blood loss
 Restore body fluids
 Administer 100% oxygen
 Assess the vitals
 Inj Hydrocortisone sodium hemisuccinate 100mg in 5 ml of water IV
 Inj Mephentermine
 Inj Atropine
 Narcotic analgesic

41. DRUG RELATED EMERGENCIES
• Approximately 85% of ADRs result from the pharmacologic effects of the
drug, whereas 15% result from immunologic reactions.(Nelson 1996)
• Allergic Reaction (Anaphylaxis)
• Allergy - a hypersensitive state acquired through exposure to a particular
allergen, re-exposure to which produces a heightened capacity to react.
• Most anticipated, acute life threatening – Type I
Nelson KM, Talbert RL: Drug-related hospital admissions, Pharmacotherapy 16:701–707, 1996

43. reference :-Stanley f. Malamed. Medical emergencies in the
dental office. 7th edition

44. reference :-Stanley f. Malamed. Medical emergencies in the
dental office. 7th edition

45. DEFINITIVE CARE :
Administer :
Antihistamines
Diphenhydramine Oral/IM/IV > 30kg 50 mg
15-30 kg 25 mg
ADRENALINE 0.1 to 0.5mL of 1:1000 IM 0r IV
Administer Oxygen
Monitor Vital signs
Histamine blocker IM
Corticosteroid IV or IM
Consider salbutamol inhaler if wheezy- 2 activation or 10
activation via a spacer.
ANAPHYLAXIS ALGORITHM

46. Local anesthesia overdose (toxicity)
• Drug overdose is the result of overly high blood levels of drug in various target
organs and tissues.
• Cause:
• Unusually slow biotransformation of the drug
• Dose of LA administered is too large
• LA administered in blood vessel
• Slow elimination of drug through kidneys
• Rapid absorption of LA from site of injection.

48. Recognize the problem
Low to moderate overdose Severe overdose
•Talkativeness, slurred speech
•Apprehension, confusion
•Excitedness
•Muscular twitching, tremor of
face & extremities
•Increased blood pressure
•Increased heart rate
•Increased respiratory rate
•Generalized tonic-clonic seizures
•CNS depression
•Reduced blood pressure
•Reduced heart rate
•Reduced respiratory rate
•Headache, dizziness
•Blurred vision, inability to focus
•Ringing ears
•Numbness of tongue, lips
•Disorientation
•Loss of consiousness

51. Orthostatic Hypotension
• Decreased blood pressure associated with an abrupt change in
patient position.
• Predisposing factors:
• Prolonged period of recumbency or convalescence
• Late stage pregnancy
• Advanced age
• Addison's disease (adrenal insufficiency)
• Chronic postural hypotension

52. Clinical manifestations
• Precipitous drops in blood pressure and patient lose
consciousness whenever they stand or sit upright.
• Patient has prodromal signs and symptoms like
lightheadedness, blurred vision, pallor, dizziness
• Heart rate during postural hypotension increases than
baseline.
• Consciousness returns rapidly once the patient is returned to
the supine position

53. Management
Patient recovers consciousness
slowly reposition chair

54. Respiratory distress
Foreign body Obstruction (FBAO)
• Commonly obstructing foreign bodies in dental clinic are :
 Teeth
 Crowns
 Filling materials
 Endodontic instruments
• At the worst, they can cause complete obstruction, lung abscess or death.

55. RECOGNITION :
• Universal distress signal for an obstructed airway :
• “person cluthes the neck”.
Foreign body in Airway
Yadav RK, Yadav HK, Chandra A, Yadav S, Verma P, Shakya VK, et al. Accidental aspiration/ingestion of foreign bodies in dentistry: A clinical and legal perspective. Natl J Maxillofac Surg 2015;6:144-51
•It is an acute emergency
•presents with the respiratory arrest, stridor
•classic triad of wheezing, coughing, and
dyspnea

56. Phases of Upper Airway obstruction
Phase Signs & Symptoms
First phase Conscious
1-3 min Universal choking sign
Struggling respiration without air
movement or voice
Increased BP and heart rate
Second phase Loss of consciousness
2-5 min Decreased respiration, BP, heart rate
Third phase Coma
>4-5 min No vital signs
Dilated Pupils

57. Signs and symptoms
• About 75% of children - at the level of upper esophageal sphincter
• while roughly 70% of the adults - at the level of the lower esophageal sphincter.
Foreign body at esophageal
level
In adults
•vague presentation of something
being struck at the center of the
chest or epigastric region
•Dysphagia
•salivary drooling/pooling
In children
•Gagging
•vomiting
• retching
• neck or throat pain
•inability to feed
•failure to thrive
•recurrent aspiration
pneumonitis/pneumonia, or stridor (due
to tracheal impingement)

58. BLS Choking Adult or
Child Algorithm -
ACLS Medical
Training
Heimlich Manoeuvre : for abdominal thrust

59. Preventive precautions
• Use rubber dam- easiest, effective!
• gauze screen across the orpharynx
• high vacuum suctions
• Floss ligatures for minor items.
• use of more upright position- practiced to minimize
risk of ingestion or aspiration with special concern in
patients with diminished protective reflexes
• Instruct patients to suppress the swallowing reflex
and turn their head down if any object falls on
tongue.

60. Asthma
• It is a chronic inflammatory disorder that is characterized by reversible
obstruction of the airways.
PRESENTATION :
• Difficulty in breathing
• Wheezing
• Cough
• Rise in blood pressure
• Increase in heart rate
• Cyanosis
• Confusion
• Decreased consciousness
Malamed SF: Medical emergencies in the dental office 7th ed. St Louis

61. Predisposing factors for Acute Asthma
Causative Factors Branchial activity
Allergy
(antigen-antibody reaction)
Respiratory infection
Normal activity Normal response No asthma
Air pollution
Physical exertion
Occupational stimuli
Pharmacological stimuli
Psychological stress
Increased activity Abnormal response Asthma

62. Patient usually upright
C-A-B – Basic life support as
needed.
Give Oxygen
Salbutamol inhaler 2-3 activations
Adrenaline 0.1 to 0.5mL of 1:1000 1M
Acute severe attack?
IV Adrenaline 0.1 to 0.5 mL of 1:1000
Glucocorticosteroids IV
Asthma Algorithm

63. Dental therapy considerations:
• Use Stress reduction protocol in case of emotional stress
• Contraindication of barbiturates and opioids as they increase the risk of
bronchospasm
• Some inhalational anesthetics like ether, irritates respiratory mucosa.
• Use of local anesthesia without vasoconstrictor.

64. HYPERVENTILATION
• It is defined as ventilation in excess of that required
to maintain normal oxygen and carbon dioxide levels
in arterial blood.
Cause:
• usual cause anxiety, fear, nervousness and
emotional stress in a hysterical form at the
conscious level.
• It is more commonly seen in females.
Malamed SF: Medical emergencies in the dental office. 6th ed. St Louis: Mosby.

65. Signs and symptoms
• Dizziness
• Hard to breathe
• Shaking and trembling
• Cold clammy hands (Diaphoresis)
• Tight feeling in chest, chest pain, and palpitations
• Lightheaded, giddy, impaired consciousness
• Uncontrolled overbreathing. Respiration rate increase to 25–30/ minute.
• Globus hystericus: Feeling of lump in throat and suffocating
• Tingling in hands, feet, and perioral areas
• Increase in blood pressure and increase heart rate

66. MANAGEMENT
• Dental procedures -terminated.
• Positioning the patient in upright position, loosen
clothes
• Reassurance to the patient.
• Patient should be advised to slow the breathing rate
voluntarily by breath holding for a few seconds after
each expiration.
• Instruct the patient to cup his or her hands in front of
the mouth and nose and to breathe in and out of the
reservoir of CO2-enriched exhaled air

67. SEIZURES
• Seizures are clinical manifestations of paroxysmal excessive
neuronal brain activity.
• The term epilepsy describes a neurological manifestation
characterized by paroxysmal, loss of consciousness, with or
without convulsions.
• Predisposing factors:
• Hypoxia , hypoglycemia, hypocalcemia
• Flashing lights, fatigue, decreased physical health, a missed meal
• alcohol ingestion, physical or emotional stress, sleep etc.
a seizure is an
event.
epilepsy is the
disease involving
recurrent
unprovoked
seizures.

68. Fisher, R. S., Cross, J. H., French, J. A., Higurashi, N., Hirsch, E., Jansen, F. E., Lagae, L., Moshé, S. L., Peltola, J., Roulet Perez, E., Scheffer, I. E. and Zuberi, S. M. (2017), Operational classification
of seizure types by the International League Against Epilepsy: Position Paper of the ILAE Commission for Classification and Terminology. Epilepsia, 58: 522-53

69. FOCAL SEIZURE
• Focal seizures result from abnormal electrical activity in one area of your brain. Focal
seizures can occur with or without loss of consciousness:
• Focal seizures with impaired awareness
 involve a change or loss of consciousness or awareness.
 may stare into space and not respond normally to your environment or perform repetitive
movements such as hand rubbing, chewing, swallowing or walking in circles.
• Focal seizures without loss of consciousness.
 may alter emotions or change the way things look, smell, feel, taste or sound, but you don't
lose consciousness.
 These seizures may also result in the involuntary jerking of a body part, such as an arm or
leg, and spontaneous sensory symptoms such as tingling, dizziness and flashing lights.

70. Generalized seizures
Seizures that appear to involve all areas of the brain are called generalized seizures.
Different types of generalized seizures include:
Absence seizures
• previously known
as petit mal
seizures, often
occur in children
• characterized by
staring into space
or by subtle body
movements, such
as eye blinking or
lip smacking.
• may occur in
clusters and
cause a brief loss
of awareness.
Tonic seizures
• Tonic seizures
cause stiffening
of your muscles.
• These seizures
usually affect
muscles in your
back, arms and
legs and may
cause you to fall
to the ground.
Atonic seizures
• Atonic seizures,
also known as
drop seizures,
cause a loss of
muscle control,
which may cause
you to suddenly
collapse or fall
down.
Clonic seizures
• Clonic seizures
are associated
with repeated or
rhythmic, jerking
muscle
movements.
• These seizures
usually affect the
neck, face and
arms.
Myoclonic seizures
• Myoclonic
seizures usually
appear as sudden
brief jerks or
twitches of your
arms and legs.

71. Tonic-clonic seizures
 previously known as grand mal seizures
• Preictal phase:
 ↑in anxiety and depression, appearance of aura & soon loses
consciousness, a series of myoclonic jerks occur
 ↑ HR, B.P, bladder pressure, glandular hypersecretion, mydriasis.
• Ictal phase:
 generalized skeletal muscle contractions progresses to a extensor
rigidity of extremities and trunk – tonic component.
 Generalized clonic movements, heavy stertorous breathing,
alternate muscle relaxation and violent flexor contractions
– clonic component
• Postictal phase:
 tonic – clonic movements cease, breathing returns to normal,
consciousness gradually returns.

72. • If ictal phase lasts > 5 minutes or if seizures continue to develop with little time
between them, a condition called status epilepticus develops (life-threatening medical
emergency)
• the uncontrolled muscle activity
• IV administration of an benzodiazepine anticonvulsant (diazepam or midazolam)
should be administered.
hypoglycemia, increased oxygen
consumption, tachycardia,
hypertension, impaired ventilation,
and cardiac arrhythmias.

73. What is epilepsy ?
This is a central nervous system
disturbance involving
convulsions followed by loss of
conciousness.

74. Management:
 Most seizures last < 2 mins
 Administer oxygen
 Maintain airway
 Monitor vitals
 If seizure is lasting > 2 mins
 Activate EMS
 Establish IV
 Administer medicine.
 Diazepam
 Adult: 10-20mg IV/IM
 Pediatric: 0.2-0.5mg/kg IV/IM
 Evaluate airway maintenance.
 Evaluate cardiac rhythm.

75. Cardiac Arrest
• Cardiac arrest can occur in a patient with no previous histroy of cardiac
problems, but more likely with a history of ischemic heart disease,
previous angina or myocardial infarction.
• Cause :
 Ventricular fibrillation accounts for most sudden cardiac arrest.
 Myocardial infarction
 Hypoxia
 Drug overdose
 Anaphylaxis
 Severe infection

76. •Cardiac arrest in children may be a consequence of respiratory
or circulatory failure.
SIGN
Gasping for air
Pupils dilate
Syncope
No pulse, BP breathing

78. SUMMARY

79. References
• Stanley f. Malamed. Prevention, Preparation. In : Medical emergencies in the
dental office. 7th edition. P15-65.
• Fast TB, Martin MD, Ellis TM: Emergency preparedness: a survey of dental
practitioners, J Am Dent Assoc 112:499–501, 1986
• Reasons J. Human error: models and management. BMJ. 2000;320(7237):768–
770
• Mostafa Alhamad, Talib Alnahwi, Hassan Alshayeb, Ali Alzayer, Omran Aldawood,
Adeeb Almarzouq, Muhammad A. Nazir J Family Community Med. 2015 Sep-
Dec; 22(3): 175–179.