medical emergency..sneha -pptx

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13-01-2023
Guided by:
Dr. Monica Mahajani
Dr. Chandrahas Goud
Dr. Anup Shelke
Dr. Subodh Gaikwad
Dr. Anup Gore
Dr. Kuldeep Patil
Presented by:
Dr. Chavan Sneha S.
(1ST Year PG)

Contents:
oPrevention
oPreparation
• Syncope
• Seizure (Fit / convulsion)
• Stroke
• Hypersensitivity reaction(Anaphylaxis)
• Asthma
• Airway obstruction due to foreign body
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• Chocking
• Hyperventilation
• Angioedema
• Chest pain
• Cardiac arrest
• Acute adrenal insufficiency
• Hypoglycemia
• Hyperglycemia
• LA Emergencies
• Hemostasis
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Most
common
Emergencies
Chest
pain
Shortness
of breath
Reaction
to drug or
sedation
Bleeding
collapse
Ref: Scully’s Medical Problems in Dentistry; 7th edi.
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PREVENTION
• Taking a careful medical history,
• Assessing disease severity, scheduling and planning
treatment carefully, &
• In some cases, administering medication prior to treatment.
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PREPARATION
• Office personnel:
Preparation of dental staff members and of the office for medical
emergencies should include the following minimum requirements:
Staff training to include BLS-HCP (Basic Life Support–Healthcare
Provider)–level instruction for all members of the dental office staff,
recognition and management of specific emergency situations, and
emergency “fire drills.”
Office preparation should include posting emergency assistance
contact numbers and stocking emergency drugs and equipment.
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causes of sudden loss of consciousness
and collapse
● Simple faint
● Diabetic collapse secondary to hypoglycaemia
● Epileptic seizure
● Anaphylaxis
● Cardiac arrest
● Stroke
● Adrenal crisis
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Ref: essential of medicine for dental students; AK Tripathi;2nd edi.

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Causes of syncope:
Cardiovascular
disorders
• Arrythmias
• Aortic stenosis
• Hypertrophic
obstructive
cardiomyopathy
• Left ventricular
dysfunction
Vascular disorders
• Postural
hypotension
• Vasovagal
syncope
• Carotis sinus
sensitivity
• Cough or
micturition
syncope
Cerebrovascular
disorders
• Vertebrobasilar
insufficiency
• Basilar artery
migraine
Conditions which
resembles syncope
• Hysterical
fainting
• Anxiety
• Hypoglycemia
• seizures
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Pathophysiology
• Engle divided the mechanisms that produce syncope into four
categories, In his classic test on fainting :
MEDICAL EMERGENCIES IN THE DENTAL OFFICE, STANLEY F. MALAMED, SEVENTH Edi. EDITION
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Management
• Management of syncopal patients differs depending on the signs and
symptoms the individual exhibits.
• management of four separate stages of syncope: presyncope,
syncope, delayed recovery, and post-syncope
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• Presyncope :
Step 1: P (position)
Step 2:C →A →B (circulation-airway-breathing)

Syncope :
• Step 1: Assessment of consciousness
• Step 2: Activation of the dental office emergency system
• Step 3: P
• Step 4: C→A→B (basic life support, as needed).
• Step 5: D (definitive care).
Step 5a: administration of O2.
Step 5b: monitoring of vital signs.
Step 5c: additional procedures.
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Airway patency may be obtained
through use of the head tilt–chin
lift method. The adequacy of an airway may be
determined through use of the “look,
listen, feel” technique.
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Delayed recovery
• Possible causes of delayed recovery from syncope include: seizure,
cerebrovascular accident (stroke), transient ischemic attacks (TIA),
cardiac dysrhythmias, and hypoglycemia.
• continue to provide the necessary steps of basic life support while
awaiting arrival of the EMS team.
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Postsyncope :
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Fig: A, An aromatic ammonia vaporole respiratory stimulant. Color changes to pink when opened. B, An
aromatic ammonia vaporole is crushed between the rescuer’s fingers and held near the patient’s nose to
stimulate movement
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Unconsciousness: Differential Diagnosis
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Vasovagal syncope
• This is most common cause of common faint in normal person
• Precipitating factors: hot & crowded environment, severe pain,
extreme fatigue, prolong standing, hunger & emotional situation
• It occurs generally in sitting & standing posture
• Venous pooling may occurs during prolonged standing or sitting
posture reduces the filling of the ventricle
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Ref: Essentials Of Medicine For Dental Students, Anil K Tripathi & Kamal K Salwani 2nd Edi.

• The underfilling ventricles vigorously contracts due to increased
sympathetic activation which in turn stimulate myocardial
mechanoreceptors & vagal afferent fibers.
• This causes vasodilatation (due to sympathetic inhibition) &
bradycardia (increased parasympathetic activity).
• Vasodilatation & bradycardia produce hypotension & syncope
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Ref: Essentials Of Medicine For Dental Students, Anil K Tripathi & Kamal K Salwani 2nd Edi.

Postural hypotension (orthostatic
hypotension/ postural syncope)
• is the second-leading cause of transient loss of consciousness
(syncope) in dental settings.
• Postural hypotension is defined as a drop in systolic blood pressure
(BP) of at least 20mm Hg or of diastolic BP of at least 10mm Hg within
3 minutes of standing when compared with blood pressure from the
sitting or supine position.
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Management
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Hypersensitivity reactions
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Anaphylaxis
• In anaphylaxis, free antigen binds to immunoglobulin E, which is fixed
on mast cells and basophils; this leads to the release of vasoactive
peptides and histamine.
Medical emergencies in the dental practice; Periodontology 2000, Vol. 46, 2008, 27–4
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• The causal agents include:
penicillins – the most common cause, but also other antimicrobials
(cephalosporins, sulphonamides, tetracyclines, vancomycin)
latex
muscle relaxants
non-steroidal anti-inflammatory drugs (NSAIDs)
opiates
radiographic contrast media others – vaccines, immunoglobulins,
various foods and insect bites
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Signs and symptoms
• There may be facial flushing, pallor, cyanosis or edema.
• The skin may be cold and clammy and there may be urticaria (an itchy
rash).
• Wheezing or laryngospasm and
• tachycardia and hypotension
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• The patient should be laid flat and 0.5 ml of 1:1,000 epinephrine
(adrenaline) should be administered intramuscularly.
• Epinephrine administration should be repeated at 10-minute intervals
as necessary.
• The epinephrine has both a and b effects; it reverses peripheral
vasodilatation and reduces edema.
• It also suppresses histamine and leukotriene release.
• Adverse effects from epinephrine are rare when appropriate doses
are given intramuscularly
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Management

• A clear airway should be ensured and 100% oxygen should be
administered.
• 10 to 20 mg chlorphenamine should be given intravenously plus 100
mg of intravenous hydrocortisone sodium succinate, which helps to
reduce edema and stabilizes the mast cells.
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• Where there is a previous history of anaphylaxis, the patient should
carry a self-administered i.m. injection device, e.g. EpiPen® which
contains 300 µg epinephrine (ALK-Abelló, Hungerford, Berkshire, UK) or Twinject® (Verus
Pharmaceuticals, San Diego, California, USA) (or less commonly, an adrenaline (epinephrine)
aerosol, such as MedihalerEpi).
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• The standard dosage of adrenaline supplied by an EpiPen for
adults is 0.3mL of 1 in 1000 (0.3mg).
• Child-sized dosages (0.15mg) are available as the EpiPen JR.
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• Angioedema is triggered when mast cells release histamine and other
chemicals (essentially vasoactive peptides) into the blood, producing
rapid swelling.
• It may be precipitated by substances such as latex and drugs including
penicillin, non-steroidal anti-inflammatory drugs and angiotensin-
converting enzyme inhibitors (e.g., captopril and lisinopril). There is a
hereditary component to angioedema.
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• Swelling of the skin occurs, especially around the eyes and lips but also in
the throat and on the extremities.
• Laryngeal edema and bronchospasm lead to the same clinical situation as
anaphylaxis.
• In cases of severe angioedema, patients may be prescribed prednisolone.
• Acute allergic edema of this type can develop alone or it may be associated
with anaphylactic reactions.
• Hereditary angioedema is caused by continued complement activation
resulting from a deficiency of the inhibitor of the enzyme C1 esterase.
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Fits
• Signs and symptoms:
The signs and symptoms of fits vary widely depending on
the underlying cause.
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• Diagnosis of a tonic–clonic (grand mal) seizure is as follows: loss
of consciousness with rigid, extended body, which is sometimes
preceded by a brief cry widespread jerking movements possible
incontinence of urine and/or faeces slow recovery
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Management
• In most cases the main aim of management is to prevent the patient
from injuring themselves during the fit.
• If a fit has stopped and the patient is in the immediate aftermath
(post-ictal phase) they should be placed in the recovery position.
• If the convulsions are ongoing, 10–20 mg diazepam should be given
intravenously, slowly.
• It may be appropriate to abort dental treatment if a patient
experiences a fit during treatment.
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The main causes of chest pain
• Angina
• Myocardial infarction
• Pleuritic, e.g., pulmonary embolism
• Musculoskeletal
• Esophageal reflux
• Hyperventilation
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Signs and symptoms
• The pain of angina and myocardial infarction may be very similar
comprising a crushing central chest pain (like a tight band around the
chest) radiating to the left arm (usually) or mandible.
• There may be breathlessness and vomiting and the patient may lose
consciousness.
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Management
• A calm and reassuring manner from the practitioner is important.
• Glyceryl trinitrate should be part of the emergency drug box in case
patients do not have their own medication with them.
• If a myocardial infarction is suspected, at an early stage, 300 mg
aspirin should be administered to be chewed (if not contraindicated).
• The patient will be most comfortable in a sitting position.
• Ensure that the airway is maintained and administer a 50 ⁄ 50 mix of
nitrous oxide and oxygen, which has analgesic and anxiolytic effect
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• Chronic respiratory disorders can lead to cardiac failure, so-called cor
pulmonale.
• a more acute respiratory problem may cause respiratory arrest, which
then proceeds to cardiac arrest.
• Previous angina or myocardial infarction predispose to cardiac arrest.
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• Possible causes of cardiac arrest include:
myocardial infarction, choking, bleeding, drug overdose, and hypoxia
• Signs and symptoms:
The patient loses consciousness and there is no respiration or pulse
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Diagnosis
• Absence of ventilation
• Absence of circulation
• Unresponsive
• Dilated pupil
• Comatosed patient
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Management
■ Basic life support comprises:
There are two underlying main themes – first the need to increase the
number of chest compressions given to a victim of cardiac arrest and
second, the importance of keeping the guidelines simple.
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CPR (cardiopulmonary resuscitation)
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• start CPR if a person:
• is unconscious
• is not responding to you
• is not breathing, or is breathing abnormally

How to perform CPR — adults
• steps before starting CPR (Use the phrase “doctor’s ABCD” — DRS ABCD :
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• Carry out chest compressions:
1.Place the patient on their back and kneel beside them.
2.Place the heel of your hand on the lower half of the breastbone, in the centre of the
person’s chest. Place your other hand on top of the first hand and interlock your
fingers.
3.Position yourself above the patient’s chest.
4.Using your body weight (not just your arms) and keeping your arms straight, press
straight down on their chest by one third of the chest depth.
5.Release the pressure. Pressing down and releasing is 1 compression.
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• Give mouth-to-mouth:
1. Open the person’s airway by placing one hand on the forehead or top of the head and your other hand under
the chin to tilt the head back.
2. Pinch the soft part of the nose closed with your index finger and thumb.
3. Open the person’s mouth with your thumb and fingers.
4. Take a breath and place your lips over the patient's mouth, ensuring a good seal.
5. Blow steadily into their mouth for about 1 second, watching for the chest to rise.
6. Following the breath, look at the patient’s chest and watch for the chest to fall. Listen and feel for signs that air
is being expelled. Maintain the head tilt and chin lift position.
7. If their chest does not rise, check the mouth again and remove any obstructions. Make sure the head is tilted
and chin lifted to open the airway. Check that yours and the patient’s mouth are sealed together and the nose
is closed so that air cannot easily escape. Take another breath and repeat.
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• Give 30 compressions followed by 2 breaths, known as “30:2”. Aim
for 5 sets of 30:2 in about 2 minutes (if only doing compressions
about 100 – 120 compressions per minute).
• Keep going with 30 compressions then 2 breaths until:
• the person recovers — they start moving, breathing normally,
put them in the recovery position; or
• it is impossible for you to continue because you are exhausted; or
• the ambulance arrives and a paramedic takes over or tells you to
• Doing CPR is very tiring so if possible, with minimal interruption,
swap between doing mouth-to-mouth and compressions so you
can keep going with effective compressions.
• If you can’t give breaths, doing compressions only without stopping
may still save a life.
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How to perform CPR — children over 1 year
• Use these instructions only if the child's chest is too small for you to use both
hands to do chest compressions. Otherwise, use the instructions for adult
CPR above.
• (Use the phrase “doctor’s ABCD” — DRS ABCD
• To carry out chest compressions on a child
• To give mouth-to-mouth to a child
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How to perform CPR — babies under 1 year
• (Use the phrase “doctor’s ABC” — DRS
ABC )
• To carry out chest compressions on a baby:
1.Lie the baby/infant on their back.
2.Place 2 fingers on the lower half of the
breastbone in the middle of the chest and
press down by one-third of the depth of the
chest.
3.Release the pressure. Pressing down and
releasing is 1 compression.
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To give mouth-to-mouth to a baby:
1.Tilt the baby/infant’s head back very slightly.
2.Lift the baby/infant’s chin up, be careful not to rest your hands on their throat because this
will stop the air getting to their lungs from the mouth-to-mouth.
3.Take a breath and cover the baby/infant’s mouth and nose with your mouth, ensuring a
good seal.
4.Blow steadily for about 1 second, watching for the chest to rise.
5.Following the breath, look at the baby/infant’s chest and watch for the chest to fall. Listen
and feel for signs that air is being expelled.
6.If their chest does not rise, check their mouth and nose again and remove any
obstructions. Make sure their head is in a neutral position to open the airway and that there
is a tight seal around the mouth and nose with no air escaping. Take another breath and
repeat.
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• Give 30 compressions followed by 2 breaths, known as “30:2”.
Aim for 5 sets of 30:2 in about 2 minutes (if only doing
compressions about 100 – 120 compressions per minute).
• Keep going with 30 compressions to 2 breaths until:
• the baby/infant recovers — they start moving, breathing
or responding — then put them in the recovery position (see
• it is impossible for you to continue because you are
• the ambulance arrives and a paramedic takes over or tells you
• If you can’t give breaths, doing compressions only without
stopping may still save a life
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Using an automated external defibrillator (AED)
• Using an AED can also save someone’s life. You do not need to be trained to use an
AED since the AED will guide you with voice prompts on how to use it safely.
1.Attach the AED and follow the prompts.
2.Continue CPR until the AED is turned on and the pads attached.
3.The AED pads should be placed as instructed and should not be touching each
other.
4.Make sure no-one touches the person while the shock is being delivered.
5.You can use a standard adult AED and pads on children over 8 years old.
6.Do not use an AED on children under 1 year of age.
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Vasovagal Shock
• it may be life- threatening due to hypoxia.
• It is sudden dilatation of peripheral and splanchnic vessels
causing reduced cardiac output and shock.
• Episodes of vasovagal syncope are typically recurrent and
usually occur when the predisposed person is exposed to a
specific trigger
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Ringing in the ears (tinnitus), an uncomfortable feeling
in the heart, fuzzy thoughts, confusion, a slight inability
to speak or form words (sometimes combined with mild
stuttering), weakness and visual disturbances such as
lights seeming too bright, fuzzy or tunnel vision, black
cloud-like spots in vision, and a feeling of nervousness
can occur as well.
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CAUSE:
• Prolonged standing or upright sitting
• After or during urination (micturition syncope)
• Straining, such as to have a bowel movement or during
vomiting
• Standing up very quickly (orthostatic hypotension)
• During or post-biopsy procedures
• Stress directly related to trauma
• Stress
• Postural orthostatic tachycardia syndrome.
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Any painful or unpleasant stimuli, such as:
• Trauma (such as hitting one's funny bone)
• Watching or experiencing medical procedures (such as venipuncture or
injection)
• High pressure on or around the chest area after heavy exercise
• Severe menstrual cramps
• Sensitivity to pain
• Arousal or stimulants (e.g. tickling, or adrenaline)
• Sudden onset of extreme emotions
• Lack of sleep
• Hunger
• Coughing
• Being exposed to high temperatures
• Random onsets due to nerve malfunctions
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TREATMENT:
1)Avoidance of trigger
2) Exposure-based exercises with therapists if the trigger is mental or
emotional, e.g. sight of blood. However, if the trigger is a specific drug,
then avoidance is the only treatment.
3) drinks with electrolytes
4) if they experience prodromal warning signs: they should lie down
and raise their legs, or at least lower their head to increase blood flow
to the brain. If the individual has lost consciousness, he or she should
be laid down with his or her head turned to the side. Tight clothing
should be loosened.
5) Wearing graded compression stockings may be helpful.
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• Asthma is a potentially life-threatening condition that should always
be taken seriously
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Signs and symptoms
• The patient will be breathless with an expiratory wheeze and may be
using the accessory muscles of respiration. The patient will usually be
tachycardic
• Dry cough, tightness in chest, anxiety, diaphoresis, cyanosis &
confusion
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Management
• A calm and reassuring presence by the practitioner is important.
• The patient will be most comfortable in a sitting position and should
use his ⁄ her normal asthma medication.
• The drugs that may be prescribed by dental practitioners, particularly
non-steroidal anti-inflammatory drugs, may worsen asthma and are
therefore best avoided.
• Oxygen should be administered and also hydrocortisone sodium
succinate (200 mg) should be administered intravenously – this will
reduce edema.
• Nebulize with salbutamol 2.5-5mg
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Hyperventilation

• When hyperventilation itself persists it is extremely distressing to the
patient. Anxiety is the principal precipitating factor
• it may also results in Hypocarbia (low Paco2) & alkalosis
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Signs and symptoms
• The patient may feel weak and light-
headed or dizzy and may complain
of paresthesia, for example in the
hands, or may complain of muscle
pain.
• The patient may have palpitations
and chest pain; indeed patients are
sometimes convinced that they are
having a myocardial infarction.
Carpo-pedal spasm may occur if
hyperventilation is prolonged.
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Management
• Hyperventilation leads to carbon dioxide being washed out of the
body, so producing an alkalosis. Rebreathing exhaled air returns the
situation to normal. This is achieved by breathing in and out of a
paper bag applied over the mouth and nose.
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Management of a choking victim; adapted from Resuscitation Guidelines
2005 Resuscitation Council UK
General signs of choking
Attack occurs while eating ⁄ misplaced dental instrument ⁄ restoration
• Victim may clutch his neck
Signs of mild airway obstruction
Response to question Are you choking?
• Victim speaks and answers YES! Other signs
• Victim is able to speak, cough and breathe
Signs of severe airway obstruction
Response to question Are you choking?
• Victim unable to speak
• Victim may respond by nodding
Other signs
• Victim unable to breathe
• Breathing sounds wheezy
• Attempts at coughing are silent
• Victim may be unconscious
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• If it is suspected that a foreign body has been inhaled in the context
of dental practice, the patient must be referred for chest X-ray.
• Radiographs will be taken in two planes (postero-anterior and lateral).
• The foreign body is most likely to be seen in the right lung
• Bronchoscopy or even thoracotomy may be required to retrieve the
foreign body.
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Abdominal thrust (formerly the Heimlich manœuvre).

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Technique for an infant with an obstructed airway.
(From Chapleau W: Emergency first responder: making the difference, St. Louis, Mosby, 2004.)

Prevention of airway obstruction:
• Use rubber dam whenever possible
• Proper positioning of patient
• Effective use of dental assistance & suction
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Guided by:
Dr. Monica Mahajani
Dr. Chandrahas Goud
Dr. Anup Shelke
Dr. Subodh Gaikwad
Dr. Anup Gore
Dr. Kuldeep Patil
Presented by:
Dr. Chavan Sneha S.
(1ST Year PG)

Acute Adrenal Insufficiency
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• Adrenal insufficiency may follow
long-term administration of oral
corticosteroids and can persist
for years after stopping therapy.
Structure of the adrenal gland, representative zones, and their main secretory products and physiologic actions. (Adapted from
Patton KT and Thibodeau GA: Anatomy and physiology, 7th edition, St. Louis, 2010, Mosby. In Little JW, Fallace D, Miller C, Rhodus N: Dental management of the medically compromised
patient, 7th edition, St. Louis, Mosby, 2007.)
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Pathophysiology : Normal adrenal function
A, The anterior pituitary gland increases production of adrenocorticotropic hormone (ACTH), which leads to
adrenocortical stimulation and increased adrenal secretion of endogenous corticosteroids.
B, An inhibited anterior pituitary produces less ACTH. Decreased blood levels of ACTH result in inhibition of
adrenal cortex and decreased production of corticosteroids.
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.
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Pathophysiology : Adrenal insufficiency
feedback mechanisms operating in
the patient with Addison’s disease.
Corticosteroid blood levels are fixed,
depending on the total milligram
dose administered during the day
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Diabetic Emergencies
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• If hypoglycemia occurs, glucose should be given by mouth as tablets,
syrup, or a sugary drink, if the patient can cooperate.
• For those patients who are not able to cooperate, glucose is also
available as an oral gel in a dispenser (GlucoGel). If these measures
are impossible or ineffective, for example in an uncooperative, semi-
conscious or comatose patient, the usual treatment of first choice is
glucagon (1 mg ⁄ ml injection) 1 mg by intramuscular or subcutaneous
injection
Bavitz JB. Emergency management of hypoglycaemia and hyperglycemia. Dent Clin North Am 1995: 39: 587–594.
Jowett NI, Cabot LB. Diabetic hypoglycaemia and the dental patient. Br Dent J 1998: 185: 439–442.
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Signs and symptoms
• There may be uncharacteristic aggression, drowsiness and a moist
skin.
• Pulse may be rapid and full and blood sugar will be low.
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Preoperative management in type 1 diabetes
mellitus – fasted patient
• The patient should be first on the list of patients
• All long-acting insulin should be stopped the night before surgery
• Intravenous access should be obtained at an early stage
• If surgery is in the morning, all subcutaneous morning insulin should
be stopped
• If surgery is in the afternoon, the usual short-acting insulin should be
given in the morning at breakfast but no medium or long-acting insulin
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• The urea and electrolytes should be checked on the morning of
surgery and an intravenous infusion of 1 litre of 5% dextrose with 20
mmol potassium chloride over 8 hours should continue until the
patient is eating normally. Dextrose may need constant infusion to
maintain the blood glucose
• 50 units of short-acting insulin should be added to 50 ml 0.9%
saline, which can be given by an infusion pump, and is given according
to a sliding scale that can be adjusted dependent on the blood glucose
measurements
• The blood glucose measurements should be checked hourly aiming
at a level of 7–11 mmol ⁄ l
• Postoperatively the intravenous insulin and dextrose, potassium
chloride and sliding scale should be continued until the patient is
eating
• Finger-prick glucose should be checked every 2 hours
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Fig:Example of a portable glucose monitor. (From Perry AG,
Potter PA, Ostendorf W: Clinical nursing skills and technique, ed 8, St. Louis,
Mosby, 2014.)
Fig:The blood sample is then applied to the test
strip and removed at the proper time. (From Sorrentino S:
Mosby’s textbook for long-term care nursing assistants, St. Louis, Mosby, 2011.)
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General instructions for use of self-monitoring
blood glucose meters:
1. Wash hands with soap and water and dry completely or clean the
area with alcohol and dry completely.
2. Prick the finger with a lancet.
3. Hold the hand down and hold the finger until a small drop of blood
appears; catch the blood with the test strip.
4. Follow the instructions for inserting the test strip and using the self-
monitoring blood glucose meter.
5. Record the test result.
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Preoperative management in type 2 diabetes
mellitus – fasted patient
• These patients may be managed by attention to diet or, more
commonly, use of oral hypoglycemics.
A fasting blood glucose of >10 mmol ⁄ l may require management
along the lines of a type 1 diabetic
• Patients taking a long-acting sulfonylurea should have the dose
halved the day before surgery and the tablet should be omitted
altogether on the day of surgery.
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• The fasting blood glucose level should be checked on the
morning of surgery and treatment is only needed if the level is
more than 15 mmol. The blood glucose level should be
monitored in any event using a finger-prick blood sample
• If the blood glucose level is more than 15 mmol, insulin should
be used
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• Other options available today include the use of continuous
subcutaneous infusions with portable insulin pumps, which require
subcutaneous needle insertion only every 48 hours.
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• Insulin pumps have the advantage of eliminating the requirement for
injections of insulin, delivering insulin doses more accurately,
improving hemoglobin A1c measurements, minimizing episodes of
severe hypoglycemia, and generally improving quality of life for
diabetic patients.
• Use of an insulin pump can lead to weight gain and can produce
diabetic ketoacidosis if the catheter becomes displaced.
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Classification of oral agents used to treat type
2 diabetes:
From American Diabetes Association: Type 2 diabetes in children and adolescents, Pediatrics 105:671–680, 2000.
106
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Currently available insulin preparations:
From Grady R, editor: Diabetes forecast, 2006,Alexandria, VA, American Diabetes Association, 2006.
107
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Local Anesthetic Emergencies
108
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Potential problems with local analgesia
Local anesthetic allergy
Cardiovascular reactions
• Palpitations
• Myocardial infarction
• Hypotension
• Hypertension
Facial palsy or diplopia
109
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Management of an intravascular local anesthetic injection
• Stop local anesthetic injection
• Lay the patient flat with legs raised
• Maintain the airway
• Reassure the patient that they should recover within 30 minutes
13-01-2023 110

Management of a broken needle in a dental patient
If tip is visible
• Remove with artery forceps
If tip is not visible
• Inform the patient
• Arrange immediate maxillofacial referral
• Advise the patient against moving the mandible as much as possible
• Ensure accurate records and inform Protection Societies
111
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Sedation emergencies
• These are usually avoidable by careful technique, but may relate to
overdose or hypoxia or both either of these situations can lead to a
respiratory arrest if not addressed and the patient will be obviously
cyanosed.
• Management:
No further sedation agent should be given.
Open and maintain the airway and give oxygen; ventilate the patient.
If an overdose is suspected consider the use of flumazenil.
112
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Systemic conditions leading to a potential
deficiency in hemostasis
• Liver impairment and ⁄ or alcoholism
• Renal failure
• Patients receiving cytotoxic medication or radiotherapy
• Thrombocytopenia, hemophilia, or other known
disorders of hemostasis
114
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Emergencies arising from impaired hemostasis
• The use of local measures, such as suturing and packing with a
hemostatic agent, for example oxidized cellulose (Surgicel) or collagen
sponge (Haemocollagen), both of which are resorbable, should be
considered.
• Bone wax is a useful method of arresting persistent bony oozing. The
minimum amount of bone wax possible should be used because of
the risk of development of a foreign body granuloma
115
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• A review of over 500 reports, in which anticoagulation was stopped
before a variety of dental procedures, reported the following: the
majority of patients had no adverse effects but four patients
experienced fatal thromboembolic events and one patient
experienced embolism which was non-fatal.
• Reports from the literature have also suggested that stopping
warfarin treatment may lead to a hypercoagulable state as the result
of a rebound phenomenon.
 Wahl MJ. Dental surgery in anticoagulated patients. Arch Intern Med 1998: 158: 1610–1616.
 Wahl MJ. Myths of dental surgery in patients receiving anticoagulant therapy. J Am Dent Assoc 2000: 131: 77–81
 Webster K, Wilde J. Management of anticoagulation in patients with prosthetic heart valves undergoing oral and
maxillofacial operations. Br J Oral Maxillofac Surg 2000: 38: 124–126.
116
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• Tranexamic acid is an antifibrinolytic agent whose primary action is to
block the binding of plasminogen and plasmin to fibrin, thereby
preventing fibrinolysis.
• There is limited published evidence, but has been suggested that,
compared with no local measures, tranexamic acid mouthwash as a
4.8% preparation reduces postoperative bleeding in anticoagulated
patients
Sindet-Pederson S, Ramstro¨m G, Bernvil S, Blomba¨ck M. Hemostatic effect of tranexamic acid
mouthwash in anticoagulant treated patients undergoing oral surgery. N Engl J Med 1989: 320: 840–843
117
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Problems with medication and hemostasis
• Patients who have liver failure can be difficult to evaluate with regard
to the risk of oral bleeding post surgically.
• In patients with hepatic problems, care should be exercised in the use
of opioid analgesics, for example morphine, and sedatives such as
diazepam. Smaller doses should be used for drugs that are
metabolized by the liver.
• The use of paracetamol should be avoided in the presence of liver
failure and alcoholism.
Lockhart PB, Gibson J, Pond SH, Leitch J. Dental management considerations for the patient with an
acquired coagulopathy. Part I: coagulopathies from systemic disease. Br Dent J 2003: 195: 439–445.
118
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Acute pain management
• Pain results from damage to tissue that induces the release of
chemicals, which include prostaglandins, serotonin, bradykinin,
thromboxane, leukotrienes, and substance P.
• ladder of analgesia:
i. Severe pain - paracetamol and injected opioid e.g. morphine
ii. Moderate pain - paracetamol with or without an oral opioid or non-
steroidal
iii. Mild pain - paracetamol
119
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Summary
• Medical emergencies occurring in dental practice can be
alarming.
• The keys to minimizing alarm are taking a thorough history
so that possible emergencies can be, to some extent,
anticipated, and having a good working knowledge of how
to manage emergencies, should they arise.
120
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References:
13-01-2023
121
1. MedicalEmergenciesInTheDentalOffice,StanleyF.MALAMED,SEVENTHEdi.Edition
2. MedicalEmergenciesInTheDentalPractice;Periodontology 2000,Vol.46,2008,27–4
3. EssentialOfMedicineForDentalStudents;AKTripathi;2nd Edi.
4. Scully’sMedicalProblemsInDentistry;7th Edi.
5. Chapleau W: Emergency first responder: making the difference, St. Louis, Mosby, 2004 Jowett NI, Cabot LB. Diabetic hypoglycaemia
andthedentalpatient. BrDentJ1998: 185:439–442.
6. AmericanDiabetesAssociation: Type2 diabetes inchildrenand adolescents,Pediatrics105:671–680, 2000.
7. GradyR,editor:Diabetesforecast,2006,Alexandria,VA,AmericanDiabetesAssociation,2006.
8. WahlMJ.Dentalsurgeryinanticoagulatedpatients.ArchInternMed1998:158:1610–1616.
9. WahlMJ.Mythsofdentalsurgeryinpatientsreceivinganticoagulanttherapy.JAmDentAssoc2000:131:77–81
10. Webster K, Wilde J. Management of anticoagulation in patients with prosthetic heart valves undergoing oral and
maxillofacialoperations.BrJOralMaxillofacSurg2000:38:124–126.
11. Sindet-Pederson S, Ramstro¨m G, Bernvil S, Blomba¨ck M. Hemostatic effect of tranexamic acid mouthwash in
anticoagulanttreatedpatientsundergoingoralsurgery.NEnglJMed1989:320:840–843
12. Lockhart PB, Gibson J, Pond SH, Leitch J. Dental management considerations for the patient with an acquired
coagulopathy.PartI:coagulopathiesfromsystemicdisease. BrDentJ2003:195:439–445.

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