MEDICAL EMERGENCIES IN DENTAL THEATER AND SOLUTION.

1. DOCTORS
1

2. MEDICAL EMERGENCIES
IN DENTAL PRACTICE
Dr. Naresh Sen
MD(Medicine), DM (Cardio),
PhD(Cardio), FACC , FESC,
FRCP, FACP, FRSM, FCCP,FAHA
CONSULTANT CARDIOLOGIST 2

3. CONTENTS
Introduction
Types of emergencies
Prevention
Preparation
Management
Summary
Conclusion
References
3

4. INTRODUCTION
4

5. STRESS!!
SYNCOPE SEIZURE
ANGINA
ASTHMATIC
ATTACK
HYPOGLYCAEMIA
CARDIAC
ARREST
ALLERGIES
HYPERVENTILATION MYOCARDIAL
INFARCTION
58%
42%
5

6.  Comprehensive medical history
 Vigilant observation & prompt recognition of
symptoms of an emergency
 Basic life support
 Affiliation to definitive medical care
6

7. COMPREHENSIVE MEDICAL HISTORY
•Thorough questionnaire
•Past medical history
•Familial disease history
•Psychological/ social status
•Diet
7

8. BASIC LIFE SUPPORT
•Primary response to all emergencies.
•P-A-B-C-D
•Position>Airway>Breathing>Circulation>Def
ibrillation(ACLS)
8

9. 9
NYHA PHYSICAL STATUS CLASSIFICATION

10. 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.  UNCONSCIOUSNESS / SYNCOPE
 Vasodepressor Syncope
 Postural/Orthostatic Hypotension
 Acute Adrenal Insufficiency
 Hypoglycemia
 SEIZURES
 RESPIRATORY EMERGENCIES
 Airway Obstruction
 Hyperventilation
 Asthma
11
Contd…

12.  CARDIOVASCULAR EMERGENCIES
 Angina Pectoris
 Myocardial Infarction
 DRUG RELATED EMERGENCIES
 Overdose Reactions
 Allergies
 FUNCTIONAL EMERGENCIES
 Needle Stick Injury
 Needle Breakage
12

13.  “Sudden transient loss of consciousness in which
one shows no responsiveness to non-deliberate
environmental stimuli”
 Predisposing factors:
 STRESS
 IMPAIRED PHYSICAL CONDITION
 HYPOGLYCEMIA
 Webster-Merriam’s Medical Dictionary. 12th ed.
Baltimore:Williams;2011.“syncope”;p.348
13

14.  Via prevention of predisposing factors:
 Use of psychosedative drugs
 ingestion-alprazolam(4mg), diazepam(5mg)
 i.m/i.v administration-butorphenol(1mg), midazolam(5mg)
 inhalation-N2O+O2 (15%+85%)
 Persuasion/Hypnosis
14
MANAGEMENT OF MEDICAL EMERGENCIES IN
DENTAL PRACTICE - 60

15. 15
Stress=Tachycardia=Carotid
body & sinus stimulation
Vagal stimulation= Bradycardia,
Vasodilation=Decreased
cerebral blood flow
Reflexive response to re-
establish cerebral blood
flow=syncope

16. 16
Pt attains upright
position
SBP falls =<60mm of Hg
due to ANS response
failure
Cerebral blood
flow<critical level
Loss of consciousness
Supination=revival
PATHOLOGY
Drugs
Prolonged
recumbency /
convalescence
Late stage
pregnancy
Varicosities
Addison’s Disease
Severe exhaustion
Shy-Drager
Syndrome
ETIOLOGY

17. 17
Cause1
• Sudden supplement withdrawal
in Addison’s disease pts.
Cause2
• Stress, either physiological or
psychological.
Cause3
• Bilateral adrenalectomy pts.
Cause4
• Trauma/thrombosis/tumour of
adrenals
Syncope caused due to lack of an adrenaline response in
medullary deficient patients resulting from:-

18. 18
Empty
stomach/
Morning
insulin
Low blood
glucose
level=<50mg/
100ml
Perilous/
anxious
disposition
Weakness/dizzine
ss, pale skin,
depressed
respiration
Unattended>>
Loss of
consciousness/s
yncope

19.  Treat the underlying cause
 Immediate symptomatic therapy includes:
 Recognition of unconsciousness
“Shake & shout”
Check for protective reflexes
 Management
Position victim-supination
Assess & open airway-head tilt, chin lift
Airway patency, breathing, circulation-look, listen & feel
Artificial ventilation & cardiac massage-cardiopulmonary
resuscitation
19
BLS

20. 20

21.  EPILEPSY- “A chronic brain disorder of various etiologies
characterized by recurrent seizures due to excessive
neuronal discharge”
 SEIZURE/ICTUS- “A paroxysmal disorder of cerebral
function characterized by a short attack involving changes
in the state of consciousness, motor activity, or sensory
phenomena”
 TONUS- “Neuromuscular dysfunction characterised by
sustained contraction and tonicity of all striated muscles”
Webster-Merriam’s Medical Dictionary. 12th ed. Baltimore:Williams;2011. “Epilepsy”, “Seizure”, “Tonus”;
p166,327,428
21

22.  CLONUS- “An abnormality in neuromuscular activity
characterized by rapidly alternating muscular
contraction and relaxation”
 POST-ICTAL PHASE- “A phase of centralised
neuronal depression following a clonic seizure in
which the subject demonstrates generalised
muscular relaxation observable as deep slumber”
 STATUS EPILEPTICUS- “A prolonged repetitive
seizure with no recovery between attacks leading to
a life-threatening emergency situation”
Webster-Merriam’s Medical Dictionary. 12th ed. Baltimore:Williams;2011.“Clonus”, “Post-Ictal Phase”,
“Status Epilepticus”; p98,279,369
22

23.  TYPE I-Absence Seizures/Petit Mal Epilepsy
 TYPE II-Myoclonic Seizures
 TYPE III-Clonic Seizures
 TYPE IV-Tonic Seizures
 TYPE V-Tonic-Clonic Seizures/Grand Mal Epilepsy
 TYPE-VI-Atonic Seizures
23
78%
11%
3%
4.8%
1%
2.2
%

24.  If pt is a known epileptic, make sure he/she has
taken their regular dose of anti-convulsant on the
day of appointment.
 Instruct him/her to alert you as the aura of the
impending seizure manifests itself.
 Inhalational sedation, based on individualised
severity levels.
 Keep life support equipment ready in case of an
emergent status epilepticus.
24

25.  Self limiting emergency
 Remove dangerous objects from the mouth and
around the pt.eg. sharp instruments, needles,
etc.
 Loosen any tight clothing.
 Avoid restraining the pt.
 In case the ictus fails to subside within a
maximum of 10 minutes, declare status
epilepticus and proceed with BLS + definitive
care. 25

26. RESPIRATORY
EMERGENCIES
26

27.  May occur due to:
 Pathology in the airway
 Dental instruments
 Tongue
 Patient demonstrates symptoms ranging from
coughing, gurgling, gagging to choking & gasping with
panic.
 Aspired object may pass into the trachea or the
oesophagus
27

28. 28

29.  Rubber dam
 Oral packing
 Chair position
 Dental assistant
 Magill’s intubation forceps
29

30.  Re-establishment of airway:
 NON INVASIVE PROCEDURES
o Forceful coughing
o Back blows
o Heimlich Maneuver
o Chest thrust
o Finger sweeps
 INVASIVE PROCEDURES
o Tracheotomy
o Cricothyrotomy
30

31. 31

32.  Excessive rate and depth of respiration leading to
abnormal loss of carbon dioxide from the blood
primarily predisposed to anxiety.
 Characterised by:
 Rapid short strained breaths
 Cold Sweats
 Palpitations
 Dizziness
 Chest muscle fatigue
 Prevention includes practicing stress reduction
protocols and administration of psychosedatives.
32

33. Anxiety
Increased rate and depth of
respiration
Increased O2/CO2 exchange by
lungs
Excessive CO2 blow off>>paCO2
decreases
Hypocapnia=decreased HCO3 ion
conc.
Increased blood
pH>>RESPIRATORY ALKALOSIS
PATHOLOGY
Position pt UPRIGHT comfortably
Reassure pt & stabilise vitals
Remove dental
materials/instruments from pt’s
mouth
Re-establish O2:CO2 ratio by
inhalation of exhaled air(85%:15%)
Check vitals & patient status again
Resume treatment procedure
MANAGEMENT
33

34.  A clinical state of hyper reactivity of the
tracheobronchial tree, characterized by recurrent
paroxysms of dyspnea and wheezing
 In diagnosed pts, not an emergency.
 Results from constriction of smooth muscles of the
tracheobronchial tree resulting from infection,
inflammation or a genetic disposition.
34

35. 35

36. EXTRINSIC OR ALLERGIC ASTHMA
 The allergens may be airborne – house dust, feathers,
animal dander, furniture stuffing, fungal spores, or plant
pollens.
 Food and drugs – cow’s milk, egg, fish, chocolate,
shellfish, tomatoes, penicillins, vaccines , asprin, and
sulfites.
 Type I hypersensitivity reaction – Ig E antibodies
produced in response to allergen
 Approximately, 50% asthmatic children become
symptomatic before reaching adulthood
36

37.  Usually develops in adult age > 35 years
 Non allergic factors – respiratory infection, physical
exertion, environmental and air pollution, and
occupational stimuli.
 Psychological and physiologic stress can also
contribute to asthmatic episodes.
 Acute episodes are usually more fulminant and
severe than those of extrinsic asthma. Long-term
prognosis also less optimistic.
37
INTRINSIC OR IDIOSYNCRATIC OR NON-ATOPIC
ASTHMA

38. 38
Recognise symptoms
Stop dental procedure
Position pt upright or bending forwards with arms
straight ahead
Administer bronchodilator
Episode terminates?
YES NO
Continue dental procedure Declare status asthmaticus
Summon EMS

39. CARDIOVASCULAR
EMERGENCIES
39

40. Heart recieves blood via coronaries
Coronaries narrow down due to
cholesterol
Reduced nutrition to respective cardiac
muscle
Treatment anxiety leads to palpitations
Greater oxygen requirements for greater
pumping
Acute Coronary
Syndrome(ACS)
ANGINA
PECTORIS
MYOCARDIAL
INFARCTION
40

41.  Definition- “A condition marked by severe pain in the
chest, often also spreading to the shoulders, arms, and
neck, owing to an indequate blood supply to the heart.”
 Types:
 Stable (classic or exertional)
 Variant (prinzmetal , vasospastic)
 Unstable (crescendo, acute coronary insufficiency)
 Prevention includes stress reduction protocol,
reassurance & psychosedation.
Webster-Merriam’s Medical Dictionary. 12th ed. Baltimore:Williams;2011. “Angina Pectoris”; p73
41

42. Recognize problem (chest pain – angina attack)
Discontinue dental treatment
Activate office emergency team
P – Position, patient comfortably usually upright
A → B → C –Assess and perform BLS
D – definitive management
HISTORY OF ANGINA PRESENT NO HISTORY OF ANGINA
Administer vasodilator and O2 Activate EMS
Transmucosal nitroglycerine spray O2 and nitroglycerine
Or sublingual nitroglycerine tablet Monitor and record
0.3 – 0.6 mg for every 5 min (3 doses)
IF PAIN RESOLVES IF PAIN DOES NOT RESOLVE
continue with dental procedure summon medical care
Administer aspirin
Continue to monitor and record vital
signs
42

43.  DEFINITION- “A clinical syndrome caused by deficient
coronary arterial blood supply resulting in ischaemia to a
region of the myocardium and causing cellular death and
necrosis.”
 Predisposing Factors:
 Atherosclerosis and coronary artery disease
 Coronary thrombosis, occlusion and spasm
 Males
 5th and 6th decades of life
 Undue stress
Webster-Merriam’s Medical Dictionary. 12th ed. Baltimore:Williams;2011. “Myocardial Infarction”; p197
43

44.  Avoid overstressing the patient
 Supplemental oxygen via nasal cannula or nasal hood
during the treatment – 3-5 L/min and 5 – 7 L/min
 Pain control during therapy – appropriate use of local
anesthesia – smaller dose with maximum effect – slow
administration
 Psychosedation – N2O – O2 is preferable
 It is strongly recommended that elective dental care is
avoided until at least 6months after MI
 Inferior alveolar NB and Posterior superior alveolar NB –
risk of hemorrhage – should be avoided
44

45.  Protocol common for both ACS outcomes
 NOTE: In a patient experiencing chest pain for the
very first time, summon medical assistance
immediately before any self-support measures.
 Thereafter, continue with immediate emergency
protocol as with AP.
45

46. 46
PORTABLE AUTOMATIC EXTERNAL DEFIBRILLATOR(AED)

47. DRUG RELATED
EMERGENCIES
47

48.  In a dental practice, commonest overdosage>>LA
 Predisposing factors for over dosage:
 Pt age/body wt
 Route of administration
 Presence of vasoconstrictor
 Type of local anaesthetic
 Drug dosage formulation vital
48
D
H
X

49.  Confusion, talkativeness, blurred speech
 Muscular twitching, facial tremor
 Headache, tinnitus
 Drowsiness, disorientation
 Elevated BP,HR,RR
 If uncontrolled, generalised tonic clonic seizures,
generalised CNS carbopathy.
49

50.  Administer basic life support
 100% oxygen, anticonvulsants
 Allow recovery to occur
 In case of continuation of symptoms, summon EMS.
50

51.  DEFINITION- “A hypersensitive state of skin and
various mucosae acquired through exposure to a
particular allergen, reexposure to which
produces a heightened emergent capacity to
react”
 Occuring via expression
of IgE in response to
allergen exposure
51

52.  Reassure pt.
 Initiate basic life support as needed.
 Administer antihistaminics (diphenhydramine 50mg),
epinephrine 0.123-0.3ml of 1:1000 i.m /s.c
 Monitor vitals regularly.
 Summon EMS
52

53. EMERGENCY DRUG KIT
MANAGEMENT OF MEDICAL EMERGENCIES IN
DENTAL PRACTICE - 60 53

54. FUNCTIONAL
EMERGENCIES 54

55.  Injury made with any sharp instrument, not just.
 Encountered more commonly by the practitioner.
 Stop procedure immediately.
 Wash skin with disinfectant.
 Treat with running water and encourage bleeding
 Dry area and cover with antiseptic dressing
 Recording medical history vital in case of an exposed
needle situation.
 Seek antidotal vaccination or treatment if necessary.
55

56.  Invariably associated with faulty techniques such
as:
 bending the needle while administering LA
 inserting the needle upto the hub
 directing the needle against resistance
 May also occur if pt jerks head during
administration.
 Most commonly with IANB.
 Elasticity of soft tissue produces rebound,
burying the fragment within.
56

57.  Inform pt of the occurance, tell him/her to remain
calm, keep mouth open and refrain from any jaw
movements.
 Retrieve the fragment, if visible, with a haemostat.
 A buried fragment needs to be located ASAP using
radiographs or CT scans & retrieved surgically.
57

58. 58

59.  ALWAYS BE PREPARED
 Prompt recognition and efficient management of
medical emergencies by a well-prepared dental team
can increase the likelihood of a safe & satisfactory
outcome.
 Basic life support training- A MUST
 As always, prevention is better than cure.
59

60.  Malamed SF. Medical Emergencies in the Dental
Practice. 4th 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
60

61.  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
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62. Thank You…!
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