overview of medical emergencies come across in dental practice with detailed information on management and treatment for dental students.

1. MEDICAL EMERGENCIES IN
DENTAL PRACTICE
BY: BIBI UMEZA
Department of Pharmacology

2. Emergency
An unforeseen combination of circumstances or the
resulting state that calls for immediate action
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3. WHY FOCUS ON MEDICAL EMERGENCIES???

4. WHY FOCUS ON MEDICAL EMERGENCIES???
Does not allow time for orderly information gathering
and formulation of a narrow differential diagnosis
before the initiation of therapy.
“When you prepare for emergency, the emercency ceases to exist”
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5. APPROACH TO A MEDICAL
EMERGENCY
Comprehensive medicalhistory
Vigilant observation &prompt
recognition of symptoms of an emergency
PREVENTION
Basic lifesupport
Affiliation to definitive medicalcare
PREPARATION
Did you know ???
A person who receives BLS has
20%increase in survival rate than one who
does not…so just act..

7. Types of
emergencies
seizures
anaphylaxis
Severe
bleeding
Shock
Tetany
Status
asthmaticus
Diabetic
ketoacidosis
Acute
addisonian crisis

8. SEIZURES

9. SEIZURE
• A paroxysmal disorder of cerebral function
characterized by an attack involving
changes in the state of consciousness
,motor activity or sensory phenomena.
• Usually sudden in onset and of brief
duration.
EPILEPSY- “A chronic brain disorder of
various etiologies characterized by
recurrent seizures”

10. Common symptoms
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11. If pt is a known epileptic, make sure he/she
has taken their regular dose of anti-convulsant
on the day of treatment.
Instruct him/her to alert you as the aura of the
impending seizure manifests itself.
Keep life support equipment ready in case of an
emergent status epilepticus.
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PREVENTION

13. If tonic clonic seizures start during a dental procedure:
• Remove instruments or dentures if any from the oral
cavity
• Place a gag or a padded tongue depressor in the
mouth between the teeth
• Turn the head to a side
• this keeps the airway clear and prevents the tongue
from falling back
• If seizures continue, 10 mg diazepam should be
given intravenously
• Dental procedure may be postponed
• If the patient continues to have seizures despite
treatment, physician should be called and managed
as status epilepticus

14. DEFINITIVE TREATMENT
• Diazepam – 10 mg i.v. , (2mg/min) repeat
every 10 minutes.
• Phenobarbitone – 100-200 mg/min, i.v.
• Carbamazepine
• Phenytoin

15. ANAPHYLAXIS

16. GENERALISED ANAPHYLAXIS
Acutely life threatening condition.
Reactions develop rapidly 5-30 minutes.
Signs and symptoms of generalised anaphylaxis are
highly variable.
Four major clinical syndromes are:
1.Skin reactions
2.Smooth muscle spasm
3.Respiratory distress
4.Cardiovascular collapse
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17. Symptoms
• Cutaneous—itching at the site of injection and/or
generalized itching, swelling of subcutaneous
tissues, eyelids, lips and tongue
• Respiratory—wheezing due to bronchospasm,
cough and laryngeal edema
• Cardiovascular—hypotension resulting in dizziness
and in more severe cases loss of consciousness.
When severe, it can be rapidly fatal. Hence, every
medical and dental practitioner must know to manage
anaphylaxis.

18. USUAL PROGRESSION OF
ANAPHYLAXIS
Skin
Eye , Nose , GI
Respiratory system
Cardiovascular system
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19. MANAGEMENT
• Terminate dental procedure & stop
administration of all drugs presently in
use.
• Position the patient comfortably.
• Basic life support as indicated.
• Monitor vital signs.
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20. Definitive Management
No CVS or respiratory involvement:
-Administration of oral or IM anti- histamine.
CVS or respiratory involvement:
- Reposition the patient
- Administration of epinephrine
- Administration of anti-histamines
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21. Uncontrolled Bleeding

22. Uncontrolled Bleeding
• Most dental procedures cause some bleeding.
• It is mostly minor and local application of mild
pressure for 10–20 seconds would generally arrest
bleeding.
• If bleeding continues, a cotton swab dipped in 1%
adrenaline solution may be used as a pack. Ice pack
for a few minutes may also be tried.
• Gel foam may be used in more severe bleeding.

23. Uncontrolled bleeding following dental procedures
may be seen in one of the following:
• Patients on antiplatelet drugs or those with
thrombocytopenia due to any cause
• Patients on anticoagulant therapy
• Hemophiliacs
• Vitamin C deficiency
• Long-term glucocorticoid therapy.

24. SHOCK

25. SHOCK
• Shock is acute circulatory failure with
underperfusion of tissues.
• Symptoms of sympathetic overactivity are
generally seen— like pallor, sweating, cold
extremities and tachycardia.

26. • Hypovolemic shock decreased fluid volume due to
sudden loss of plasma or blood as in hemorrhage,
burns or dehydration— results in hypovolemic
shock. Fluid and electrolytes should be replaced and
BP monitored
• Septic shock is precipitated by severe bacterial
infection. It may be due to the release of bacterial
toxins—should be treated with appropriate
antibiotics apart from general measures
• Cardiogenic shock is due to failure of heart as a
pump as in myocardial infarction. IV morphine is the
drug of choice to relieve pain and anxiety

27. • Anaphylactic shock: Type I hypersensitivity reaction
causing release of massive amounts of histamine
which is triggered by antigen-antibody reaction.
Adrenaline 0.3–0.5 mL of 1:1000 solution given
intramuscularly is the drug of choice
• Neurogenic shock is due to venous pooling as
following spinal anesthesia, abdominal or testicular
trauma
Shock of any type needs immediate treatment

28. General Guidelines for the Treatment of
Shock
 The cause should be identified and treated
 The foot end of the bed should be elevated. This
increases venous return which raises the BP to some
extent
 BP and plasma should be maintained with appropriate
intravenous fluids
 Vasopressors like dopamine may be given
intravenously when the BP cannot be brought up by
IV fluids. Plasma expanders may help in maintaining
the plasma volume when there is severe hypovolemia

29.  Acid base and electrolyte disturbances should be
corrected
 Adequate urine output should be ensured.
To restore the intravascular volume, the component
that is lost should ideally be replaced-like plasma in
burns and blood after hemorrhage. But in
emergency, immediate volume replacement is
important. In such situations plasma expanders and
intravenous fluids are used.

30. Different types of IV fluids to be given
depending on the patient’s requirements.
• Isotonic Fluids
• Hypotonic Fluid
• Hypertonic Fluid

31. MEDICAL EMERGENCIES IN
DENTAL PRACTICE (part 2)
BY: BIBI UMEZA
Department of Pharmacology

32. TETANY

33. TETANY
• Tetany is due to hypocalcemia
• Other features of hypocalcemia include
- Muscle cramps,
- Paresthesias,
- Laryngospasm
- Severe cases—convulsions.

34. Management
• 5–10 mL IV calcium gluconate followed by
50–100 mL slow IV infusion promptly
reverses the muscular spasm.
• This is followed by oral calcium 1.5 g daily
for several weeks

35. Acute Addisonian Crisis

36. • Emergency condition precipitated by an infection or
sudden withdrawal of steroids after long-term
administration.
• Proper drug history is therefore very important.
• If the patient has been on glucocorticoids like
(prednisolone) for more than 2 weeks, at the time of
presenting for a dental procedure, the glucocorticoid
should be continued.
• The dentist should make sure that the patient
receives his dose of glucocorticoid on the day of
dental procedure particularly if it is a major
procedure.
Acute Addisonian Crisis

37. Symptoms of Addisonian crisis
Symptoms of Addisonian crisis include
• nausea,
• vomiting,
• weakness,
• hypotension,
• dehydration,
• hyponatremia and hyperkalemia.

38. Treatment
• Intravenous hydrocortisone hemisuccinate 100 mg
bolus followed by infusion 100 mg every 4–6 hours
is given immediately
• Once the patient recovers, switch over to oral
preparations.
• Immediate correction of fluid and electrolyte
balance is important.
• When acute adrenal insufficiency is not confirmed,
dexamethasone (4 mg IV) should be used in place
of hydrocortisone because dexamethasone does
not interfere in the estimation of hydrocortisone
levels for diagnosis

39. STATUS
ASTHMATICUS

40. Asthma
A clinical state of hyper
reactivity of the
tracheobronchial tree,
characterized by
recurrent paroxysms of
dyspnea and wheezing
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41. Signs and symptoms
Feeling of chesttightness
Dyspnea
Tachypnea
Cough
Use of Accessory/Respiratory Muscles
Agitations
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42. The most likely times for an acute
exacerbation are:
During and immediately after
local anesthetic administration.
With stimulating procedures
such as extraction.
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43. MANAGEMENT
Yes No
Continue
dental
procedure
Declare status asthmaticus
Summon EMS
Recognize symptoms
Stop dental procedure
Position pt upright or bending forwards with arms straight
ahead
Administer bronchodilators
Asthma terminates?

44. Management
• Discontinue the dental procedure and allow the
patient to assume a upright position.
• Establish and maintain a patent airway and
administer Beta 2 agonists via inhaler ornebulizer.
• Administer oxygen if possible
• If no improvement is observed and symptoms are
worsening, administer epinephrine
subcutaneously (1:1,000 solution, 0.01 mg/kg of
body weight to a maximum dose of 0.3 mg).
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45. • Begin diligent basic life support.
• Document in time form the beginningof the event.
• Alert emergency medical services.
• Maintain a good oxygen level until the patient
stops wheezing and/or medical assistance
arrives.
• Escort patient to hospital asneeded.
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46. DIABETIC
KETOACIDOSIS

47. Diabetic Ketoacidosis
May be precipitated by infection, stress or trauma.
It is more common in patients with insulin—
dependent diabetes mellitus.
Diabetic ketoacidosis is a medical emergency and
can be life- threatening.
Insulin deficiency results in severe hyperglycemia
(600–800 mg/ dL) and excessive production of
ketone bodies.

48. Clinical features
• Metabolic acidosis,
• dehydration with loss of sodium and potassium
in the urine causing electrolyte imbalance,
• impaired consciousness and hyperventilation—
may proceed to coma.
Diabetic ketoacidosis should be suspected when
the patient has IDDM,
• diabetes is uncontrolled,
• patient is under stress, or has infection and
develops the above signs and symptoms.

49. Management
• Correction of hyperglycemia
• Correction of dehydration
• Correction of acidosis
• Potassium

50. Hyperglycemic, hyperosmolar, nonketotic,
coma:
Severe hyperglycemia and glycosuria result in
severe dehydration and increased plasma
osmolarity leading to coma and has a high mortality
rate.
The treatment is similar to ketoacidosis with
correction of fluid and electrolyte imbalance and
plane insulin

51. To conclude….
The first step in management ofdental emergencies
is to prevent their occurrence
With proper knowledge medical emergencies and
related complication can be easily prevented
“When you prepare for emergency, the emergency
ceases to exist”
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52. THANKYOU