this presentation is based on the medial emergencies which we come across in our dental practice and how to handle it before taking any medical help.

1. MEDICAL EMERGENCIES
IN DENTAL PRACTICE
Presented by-
Shreya Rastogi
JR-2

2. CONTENTS
 Introduction
 Basic Life Support
 Emergency Drug Tray/ Kit
 Common Medical Emergencies
 Syncope and postural hypotension
 Acute Allergic Reaction
 Angina Pectoris
 Myocardial Infarction
 Cardiac Arrest Or Ventricular Fibrillation
 Asthmatic Attack
 Hypoglycemia
 Seizures And Status Epilepticus

3.  Hypothyroidism
 Hyperthyroidism
 Acute adrenal insufficiency
 Conclusion
 References

4. INTRODUCTION
 Medical emergencies can and do occur in the dental office
 Majority of emergencies encountered are precipitated by
the increased stress.
 Increased stress can result from fear and anxiety or
inadequate pain control.

5.  The concept of ‘‘how healthy is the patient,’’ otherwise termed
‘‘risk assessment,’’ is key in determining the likelihood of
complications. The higher the ASA class, the more at-risk the
patient is, both from a surgical and an aesthetic perspective.
 ASA Class I - A normal healthy patient
 ASA Class II - A patient with mild systemic disease
 ASA Class III - patient with severe systemic disease
 ASA Class IV - A patient with an incapacitating systemic
disease that is constant threat to life
 ASA Class V - A moribund patient not expected to survive
24 hours with or without operation
 ASA E - Emergency operation of any variety

6. URGENCIES VS EMERGENCIES
 A problem that requires
prompt response; it is not
immediately life threatening
but could become so if not
resolved promptly
– Syncope
– Hypoglycemia
– Seizure
– Asthmatic attack
– Hyperventilation
– Angina
– Mild allergic reaction
 A problem that is immediately
life threatening and requires
immediate action
– Cardiac arrest
– Anaphylaxis
– Obstructed airway
Urgency Emergency

7. PREPARATION
 Staff training
 Basic Life support training
 Training in recognition and management of specific
emergency situation
 Emergency fire drills
 Office preparation
 Posting emergency assistance number
 Stocking emergency drugs and equipments

8. BASIC LIFE SUPPORT (BLS)
 “Single important step in preparation for medical emergencies”
 In all emergency situations, initial management will always
entail the application of needed steps of basic life support
 Drug therapy is always related to a secondary role
 The ABCs of cardiopulmonary resuscitation (CPR) are
assessment and treatment, if needed of, in that order
(acc.to AHA 2010 guidelines):
A. Airway (maintain patency)
B. Breathing (respiratory movements)
C. Circulation (heart beat and blood pressure)
 Use of any emergency drugs is considered only after attending
to these ABCs.

9. The steps of basic life support by CPR

10. STEPS OF BASIC LIFE SUPPORT
 Step 1 - Assessment of consciousness
 Step 2 - Call for help
 Step 3 - Position the patient
Trendelenberg position
One situation in which modification is required-
pregnancy

12.  Step 4 - Assess and open airway
Head tilt- chin lift Jaw thrust

13.  Step 5 - Assess airway patency and breathing

14.  Step 6 - Artificial ventilation if needed

15.  Step 7 - Assess circulation
 Step 8 - Patent airway+adequate circulation– definite management
 Step 9 - External chest compression
Pressure point
One rescuer
Two rescuers

16. CHANGE FROM A-B-C TO C-A-B
 The vast majority of cardiac arrests occur in adults, and
the highest survival rates from cardiac arrests are
reported among patients of all ages who have a
witnessed arrest and an initial rhythm of VF or pulseless
VT
 In these patients , the critical initial elements of BLS are
chest compressions and early defibrillation.
 In the A-B-C sequence , chest compressions are often
delayed while the responder opens the airway to give
mouth-to-mouth breaths, retrieves a barrier device , or
gathers and assembles ventilation equipment.2

17. EMERGENCY DRUG TRAY/KIT
 Medical emergencies occur unpredictably and may sometimes
evolve into a life-threatening situation; the dental surgeon and
his team should be prepared to act swiftly and at all times.
 All medicines and equipment needed to deal with the
emergency should be available in ready-to-use condition at an
easily accessible location in the office.
 It should contain a limited number of medicines sufficient for
tackling the emergencies.
 The dentist should have knowledge about the actions, doses,
method of administration, type of formulation, indications and
contraindications, etc. of these emergency medicines.

18. EMERGENCY DRUG TRAY/KIT
 The emergency drugs should be periodically checked.
 A log book of the drugs in the tray should be kept and reviewed
every month.
 Soon to expire drugs and those used up should be replaced.

20. COMMON MEDICAL
EMERGENCIES
ENCOUNTERED IN DENTAL
PRACTICE

21.  Sudden, transient loss of consciousness, that is usually
secondary to period of transient ischemia
 Commonest cause - vaso-vagal attack, i.e. sudden reflex vagal
stimulation producing marked bradycardia and fall in blood
pressure
 Severe pain or emotional stress is the usual trigger
 More likely to occur in a patient who is unduly anxious before
the dental procedure
SYNCOPE

22. PREDISPOSING FACTORS
Psychogenic factors
 Fright
 Anxiety
 Emotional stress
 Pain
 Sight of blood or syringe
Non-psychogenic factors
 Sitting in upright position
or standing
 Hunger
 Exhaustion
 Poor physical condition
 Hot, humid environment

23. SIGNS AND SYMPTOMS
 Patient feels sick
 Sense of fainting
 Dizziness
 Nausea
 Pale and flushed skin
 Cold sweats break out
 Weak and slow pulse
 Muscles twitch
 Fall in BP
 Pupils may dilate

24. MANAGEMENT
 Lay the patient flat on the dental chair or on the ground
 Foot end should be raised a little to improve blood flow to the
brain, provided there is no breathlessness.
 Any tight clothing around the neck should be loosened.
 Mostly, no medication is needed and the patient regains
consciousness soon. The traditional method of making the
patient smell ammonia or putting a drop of alcohol into the
nose is out mooded.
 The patient is reassured and given a cup of tea or coffee with
sugar, or a fruit juice.

25. POSTURAL HYPOTENSION
 Fainting could also be due to orthostatic hypotension.
 Occurs mostly as consequence of getting up abruptly from
reclining position on the dental chair after a procedure
 Elderly patients, diabetics, those receiving α-adrenergic
blockers or other antihypertensive medication are more prone
to develop postural hypotension.
 In these patients, fainting can be avoided by bringing them to
an upright posture gradually, asking them to keep sitting for a
couple of minutes and then getting up slowly.
 The symptoms and management of postural hypotension are
the same as that of vasovagal attack (syncope).

26. ACUTE ALLERGIC REACTION
 An immediate or Type-1 hypersensitivity reaction
(anaphylaxis)
 can develop due to any medication, including the local
anaesthetic administered by the dentist, or to a dental material,
or even to the latex gloves of the dentist.
Common Allergens In Dentistry
 Antibiotics – Penicillins, Cephalosporins, Tetracyclines,
Sulfonamides
 Analgesics - Acetylsalicylic acid (aspirin), NSAIDs
 Local Anesthetics – Esters - Procaine, Propoxycaine,
Benzocaine, Tetracaine
 Preservatives - Parabens (methylparaben), Bisulfites,
metasulfites
 Other Allergens - Acrylic monomer (methylmethacrylate),

27. SYMPTOMS
 Itching
 Flushing of the skin
 Feeling of warmth
 Urticaria
 Swelling of lips/ face due to angioedema, which becomes life-
threatening if larynx gets involved
 Bronchoconstriction and even anaphylactic shock.
The reaction may sometimes develop within minutes. More
rapidly developing reaction tends to be more severe.

28. PREVENTIVE MEASURE
 Ask about any history of allergy or sensitivity to a medication.
 Medicines to which the patient has reacted in the past should
not be administered.
 Atopic patients are at a higher risk of developing a reaction or
anaphylaxis.

29. MANAGEMENT
 Position patient in upright position
 Assess A-B-C (C-A-B)
 Mild nonlife-threatening reactions like urticaria, rashes,
swelling only of lips, may be treated with an oral antihistaminic
like chlorpheniramine 4 mg or cetirizine 10 mg.
 For a rapidly developing reaction, a parenteral antihistaminic
like pheniramine 22.5–45 mg or promethazine 25–50 mg may
be injected i.m. When bronchoconstriction is prominent, it can
be counteracted by salbutamol inhalation
 For bronchospasm, laryngeal edema and anaphylaxis, only
adrenaline 0.5 mL i.m given and repeated as required.
 A parenteral antihistaminic and i.v. hydrocortisone100–200 mg
(4mg/kg) have adjuvant value.
 Simultaneously started oxygen inhalation is very important.

30. ANGINA PECTORIS
 Due to ischaemic heart disease and is characterized by sudden
onset substernal pain, which may radiate to left shoulder and
arm; occasionally also to the lower jaw and teeth.
 In the dental office may be precipitated by the anxiety while
attending the dental surgery.
 If the patient may have had attacks of angina in the past he/she
will recognise the symptoms itself.

31. CAUSES
 Coronary artery atherosclerosis
 Coronary artery spasm
 Multiple other cardiac and pulmonary etiologies:
 Aortic stenosis
 Cardiomyopathy
 Pulmonary hypertension or infarction
 Myocardial disease
 Pericarditis
 Mitral valve prolapse
 Aortic dissection

32. CLINICAL CHARACTERISTICS
 Poorly localized pain
 Usually retrosternal but may occur anywhere from lower
jaw to umbilicus
 Brief duration – 2 to10 minutes
 Moderate intensity pain described as squeezing, oppressive,
burning or heaviness
 Precipitated by
 Emotional distress
 Physical exertion
 Heavy meals
 Cold
 Walking up stairs
 Exacerbated by
 Recumbency

33. MANAGEMENT
 Administering 0.5 mg glyceryl trinitrate (GTN) tablet
sublingually or one/ two puffs of GTN oral spray (0.4 mg/ puff)
in the mouth and then closing the mouth.
(Tablets of GTN have a short shelf life of 2–3 months after opening the
container, because GTN is a volatile liquid which evaporates away slowly from
the tablets.)
 Ensure that the tablets are active when administered. It is
preferable to use the spray formulation which has a predictable
shelf life and acts faster than the sublingual tablets.
 The patient should be put in the sitting posture to reduce cardiac
preload by favouring pooling of blood in the legs.
 Anxiety should be allayed by reassuring the patient.
 Majority of angina attacks subside with one dose of GTN; those
not relieved can be given another dose after 10 min.

34. PRECAUTIONS
 Dental treatment
 Early morning appointments
 Short appointments
 Stress reduction measures
 Supplemental oxygen
 Adequate pain control
 LA containing vasoconstrictor can be used with proper
technique.
 Max safe dose of epinephrine with 2% lidocaine for cardiac
patients is 7 mg/kg which is equivalent 3
 1 cartridge of 1:50000 conc (20μg/mL)
 2 cartridges of 1:100000 conc (10μg/mL)
 4 cartridges of 1:200000 conc (5μg/mL)

35. MYOCARDIAL INFARCTION (MI)
 It is a clinical syndrome resulting from deficient coronary
artery blood supply to a region of myocardium that results in
cellular death and necrosis.
 No elective dental care for atleast 6 months postoperative.
 The pain of MI is similar to that of angina, but generally more
severe, more prolonged, and is not fully relieved even by 2
doses of GTN.
Note-It is not advisable to administer more than 2–3 doses of
GTN, because this may cause hypotension and accentuate
myocardial ischaemia

36. SIGNS AND SYMPTOMS
Symptoms
 Pain
 Nausea/Indigestion
 Weakness/Fatigue
 Dizziness
 Palpitations
 Sense of impending doom
 Lightheadedness
Signs
 Restlessness
 Acute distress
 Vomiting
 Cardiac arrhythmia
 Pallor
 Cyanosis
 Dyspnea
 Wheezing

37. MANAGEMENT
 Put the patient in a comfortable position
 Administer oxygen through a face mask. If breathing is inadequate,
ventilatory support should be provided by CPR.
 Sublingual GTN should be given(unless systolic arterial
pressure<90mmHg or heart rate<50 or>100 beats/min).
 One dispersible 300 mg tablet, or four 75 mg tablets of aspirin
should be put in a cup of water and given to drink immediately. The
purpose is to prevent progression of the thrombus by the antiplatelet
aggregatory action of aspirin.
 If possible, 3 mg morphine should be injected i.v. slowly to relieve
pain and anxiety, keeping watch on respiration and BP.
 Older patients are more susceptible to the respiratory depressant and
hypotensive actions of morphine. The i.m. route for morphine is not
suitable in this setting, because absorption of morphine from the i.m.
site may be delayed due to hypotension and reflex vasoconstriction.
 Further measures are not within the purview or competence of a
dental surgeon.

38. CARDIAC ARREST OR
VENTRICULAR FIBRILLATION (VF)
 In the dental office, cardiac arrest or VF (pulseless non-
synchronized ventricular contractions) are mostly a
consequence of acute MI.
 When cardiac arrest or VF occurs
 The patient collapses and becomes unconscious
 Pulse cannot be felt
 Heart beat cannot be felt or heard
 Breathing stops
 Skin looks pale or gray (if cyanosis develops)
 Pupils dilate a little later

39. MANAGEMENT
 Immediate institution of CPR is critical and continued till
spontaneous heart beat is restored or till expert help arrives
 Though i.v. injection of adrenaline can help in restoring heart
beat, it is not advisable in the dental office setting as
 In case of MI, adrenaline can worsen cardiac ischaemia by
increasing cardiac oxygen demand
 It may not be possible for the dentist to differentiate cardiac
asystole from VF, and VF is perpetuated by adrenaline
 The only measure which can terminate VF and restore heart
beat is application of electric shock delivered from a
defibrillator.
 Amiodarone, an antiarrhythmic drug, injected i.v. has been used
to prevent recurrences of VF; but this is not in the purview of a
dentist

40. BRONCHOSPASM/ ASTHMATIC
ATTACK
 Disease characterized by an increased responsiveness of
trachea and bronchi to various stimuli and manifested by
widespread narrowing of airways that changes in severity
either spontaneously or as a result of therapy.
 Can be:
 Extrinsic Asthma
 Intrinsic Asthma
 Status Asthmaticus

41. SIGNS AND SYMPTOMS OF ACUTE ASTHMA
Symptoms
 Feeling of chest congestion
 Cough with or without
sputum production
 Wheezing
 Dyspnea
Signs
 Tachypnea
 BP – baseline to elevated
 Tachycardia
 Diaphoresis/ sweating
 Confusion
 Cyanosis
 Supraclavicular and
intercostal retraction
 Use of accessory muscles of
respiration
 Nasal flaring

42. Terminate dental procedure
Position the patient in sitting position with arms thrown forwards
Remove dental materials from patient’s mouth
Calm the patient
Basic life support
Administer bronchodilator via inhalation
Episode terminates episode continues
Subsequent dental care Administer oxygen
Administer parentral medications
Discharge patient
Hospitalize patients
MANAGEMENT

43. MEDICATION
 Salbutamol 100 mg/ puff metered dose inhaler (MDI) - inhalation of 2
puffs, repeated if necessary after 10 minutes
 If the patient is unable to use the MDI correctly, further puffs are
given through a large volume spacer device.
 If the bronchoconstriction is still not reversed, nebulized salbutamol +
ipratropium bromide solution should be administered through an
oxygen mask.
Nebulizers are not generally kept in the dental office. In that case the
patient should be given oxygen inhalation and sent to a hospital
urgently.
 For life-threatening asthma, 0.5 mg adrenaline can be injected i.m.,
along with hydrocortisone 100 mg i.v. (as for anaphylaxis) and
medical help is summoned

44. HYPOGLYCAEMIA
 Blood glucose levels are below 3.0 mmol/L (54 mg/dl)
 Highly unlikely to develop in a non-diabetic patient coming to a
dental clinic for treatment
 Only when a diabetic who has taken insulin injection or other
hypoglycaemic medication and has missed the meal before
coming for dental treatment is likely to suffer hypoglycaemia.
Diagnostic clues:
 Sweating, tachycardia (sympathetic overactivity)
 Weakness, dizziness
 Pale, moist and cold skin (in contrast to hyperglycemia)
 Shallow respiration
 Headache
 Altered consciousness

45. MANAGEMENT
Conscious Patient
 Terminate dental procedure
 Position the patient
 BLS
 Administer 15 gms of oral
carbohydrate
 No improvement –
administer parentral
carbohydrate or glucagon if
available or intravenous
dextrose.
 Observe patient atleast for 1
hour before discharging
Unconscious Patient
 Terminate dental procedure
 Position patient in supine
patient
 BLS
 Summon medical assistance
 Definitive management (50%
dextrose iv, 1mg glucagon
im, transmucosal sugar). If
none of the two is available,
0.5mg dose of 1:1000 conc
epinephrine SC or IM every
15 minutes

46. SEIZURES, STATUS EPILEPTICUS
 Paroxysmal disorder of cerebral function characterized by
an attack involving changes in the state of consciousness,
motor activity or sensory phenomenon
 Type of seizures
 Partial seizures (focal/ local)
Simple partial seizures/ jacksonian epilepsy (without loss
of consciousness)
Complex partial seizures (with loss of consciousness)
 Generalized seizures
Absence seizures
Atypical absence seizures
Myoclonic seizure
Clonic seizures
Tonic clonic seizures
Atonic seizure

47.  Predisposing factors –
 Hypoxia
 Hypoglycaemia
 Hypocalcemia
 Stress
 Fatigue
 Missed meal
 Alcohol ingestion.
 Occurrence of seizure in an epileptic is unpredictable. An attack
is possible in the dental office or even during a dental procedure
as well.
 Generally epileptics do not voluntarily inform the dentist about
it, unless specifically asked for. The dentists should routinely
elicit history of all past and present illnesses before undertaking
any treatment.

48. MANAGEMENT OF PETIT MAL AND PARTIAL
SEIZURES
 Diagnostic clues
 Sudden onset of immobility and blank stare
 Show blinking of eyes
 Short duration
 Rapid recovery
Terminate the dental procedure
Position the patient comfortably
Seizure stops Seizure continues > 5 min
Reassure patient Summon medical assistance
Inj Diazepam 0.1 – 0.2 mg/kg i.v
Allow patient to recover Basic life support as indicated
and discharge

49. GENERALIZED TONIC CLONIC SEIZURES
 Diagnostic clues:
 Prodromal symptoms – marked anxiety or depression
 Presence of aura prior to loss of consciousness
 Preictal phase
 Loss of consciousness, epileptic cry, increase in HR and BP
upto twice baseline, apnea
 Ictal phase
 Tonic phase lasts from 10 to 20 sec - dyspnea and cyanosis .
 Clonic phase lasting for 2 to 5 min - heavy, stertous
breathing, frothing, blood from mouth, clenched teeth,
tongue biting.
 Postictal phase
 Consciousness returns, urinary and fecal incontinence due to
muscle flaccidity

50. MANAGEMENT
 Prodromal stage
 Terminate the dental procedure
 Ictal stage
 Position the patient (supine with legs elevated slightly)
 Summon medical assistance and Inj Diazepam 0.1 – 0.2
mg/kg
 Protect patient from injury
 Basic life support as indicated
 Administer oxygen
 Monitor vital signs
 Post ictal stage
 Basic life support as needed
 Reassure patient and allow to recover
 Discharge patient

51. MANAGEMENT OF STATUS EPILEPTICUS
 Prodromal stage
 Terminate the dental procedure
 Ictal stage
 Position the patient (supine with legs elevated slightly)
 Summon medical assistance
 Protect patient from injury
 Basic life support as indicated
 Administer oxygen
 Monitor vital signs
 Seizure continues > 5 min
Basic life support perform venipuncture,
until assistance arrives administer iv anticonvulsant(inj.diazepam)
administer 50% dextrose iv
definitive management
(phenytoin (15mg/kg),
Phenobarbital (10 to 15 mg/kg),
Neuromuscular blockade with pancuronium)

52. HYPOTHYROIDISM
A condition in which the thyroid gland doesn’t produce enough
thyroid hormone.
Myxedema coma is defined as severe hypothyroidism leading to
decreased mental status, hypothermia, and other symptoms
related to slowing of function in multiple organs. It is a medical
emergency with a high mortality rate.
Diagnostic clues :
• Cold intolerance
• Weakness
• Fatigue
• Dry, cold, yellow skin
• Thick tongue

53. MANAGEMENT
Terminate dental procedure
Supine position
A,B,C should be maintained
Definitive care
Summon emergency assistance
Establish iv access, if possible (5% dextrose)
Administer oxygen
IV doses of thyroxine hormone

54. HYPERTHYROIDISM
 It is the overproduction of thyroxine hormone by thyroid
gland.
Diagnostic clues:
 • Sweating
 • Heat intolerance
 • Tachycardia
 • Warm, thin, moist skin
 • Exophthalmos
 • Tremor

55. MANAGEMENT
Similar to that of hypothyroidism except that instead of
thyroid hormone, antithyroid drugs are required in this case
(eg. propylthiouracil) and Glucocorticoids to prevent the
occurance of acute adrenal insufficiency.

56. ACUTE ADRENAL INSUFFICIENCY
 It is a life threatening condition that occurs when there is not enough
cortisol (secreted by adrenal glands).
Predisposing factors-
 Addison disease
 Secondary insufficiency
 Stress
CLINICAL MANIFESTATIONS
 • Weakness and fatigue
 • Anorexia
 • Weight loss
 • Hyperpigmentation
 • Hypotension
 • Hypoglycemia
 • Nausea, vomiting
 • Syncope
 • Lethargy
 • Confusion(marked most notably)
 • Psychosis

57. MANAGEMENT
Terminate dental care
Position patient comfortably if asymptomatic
Supine with feet elevated, if symptomatic
Monitor vital signs
Summon medical assistance
Administer oxygen
Administer glucocorticoid
Additional management: provide Basic Life Support as needed
Provide oxygen as needed
Maintain iv line

61. CONCLUSION
Medical emergencies are very frequent in dental practice,
therefore the dentist should be aware of these emergencies and
the probable management for the same.
For this, the clinician should have a certified training of the
BLS and should have a thorough knowledge of all the possible
emergency drugs and the equipments present in his emergency
kit or will be required for the management of a specific
emergency. The dentist should also have a trained staff for help
in such cases.
To avoid such situations to some extent, a thorough medical
history of the patient should be recorded.
A calm dental environment is also a major factor in avoiding
such mishaps.

62. REFERENCES
1)Essentials of Pharmacology for dentistry (3rdedition)
-K.D Tripathi
2)American Heart Association (AHA) Guidelines update for
CPR and ECC (2015)
3)Atrial defibrillation and its relationship to dental care ;
B C Muzyka. J Am Dent Assoc.1999 Jul
4)Guidelines for Dental Professionals in Covid-19 pandemic
situation (Issued on 19/05/2020)