presentation in medical emergencies

1. MANAGEMENT OF
MEDICAL EMERGENCIES IN
DENTAL PRACTICE
Presented by:
Dr. AKANKSHA NARELA

2. CONTENTS
PART – 1
Introduction
Preparation for emergency
Case history
Basic life support
Chain of survival
Cardiopulmonary resuscitation
Helpline numbers
ASA physical status classification

3.  TYPES OF EMERGENCIES:
• UNCONSCIOUSNESS / SYNCOPE
Vasodepressor Syncope
Postural/Orthostatic Hypotension
Acute Adrenal Insufficiency
Hypoglycemia
• SEIZURES
• RESPIRATORY EMERGENCIES
Airway Obstruction
Hyperventilation
Asthma

4. WHAT DO YOU UNDERSTAND BY MEDICAL
EMERGENCY?
MEDICAL EMERGENCY:-
It is an injury or illness that is acute & possess an
immediate risk to a persons life or long term health..
Depending on the severity of the emergency, & the quality
of any treatment given , it may require the involvement of multiple
levels of care, from first aiders to emergency medical teams…

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

6. PREPARATION FOR EMERGENCIES
Most emergencies can be prevented by adequate preparation of the
patient and staff. The following are suggested guidelines:
• Obtain a medical history on every patient and update it at each visit.
Obtain physician consultation where necessary.
• When confirming appointments, remind patients to take their normal
medications on the day of their appointment.

7. Procedures should be scheduled around meal times for
diabetics. Patients using inhalers or nitroglycerin should have these with
them in the event of an asthma or angina attack which is precipitated by
the stress of dental treatment.
• Staff members should be trained to monitor and interpret vital signs.
These should be taken at the initial visit as a “baseline reading” and at
each subsequent visit for those patients whose medical history
indicates they may be “at risk.”

8. • All staff members should be trained in basic first aid procedures and
basic life support (CPR).
• The office should have a written emergency plan. Each staff practice
their particular function in an emergency, and emergency telephone
numbers should be posted at each phone.
• Staff members should be aware of the signs of stress and ways these
can be alleviated.

9. • Office personnel should be aware of the signs and symptoms indicating
an emergency. Each office should have an emergency kit readily
available and each staff member should know where it is located.
• All staff should be aware of their legal responsibilities when responding
to an office emergency. Remember—the “best handled” medical
emergency will always be the one that never happened

10. • COMPREHENSIVE MEDICAL HISTORY
• VIGILANT OBSERVATION & PROMPT RECOGNITION OF SYMPTOMS
OF AN EMERGENCY
• BASIC LIFE SUPPORT
• AFFILIATION TO DEFINITIVE MEDICAL CARE
HOW WE CAN PREVENT ?

11. COMPREHENSIVE MEDICAL HISTORY
•Thorough questionnaire
•Past medical history
•Familial disease history
•Psychological/ social status
•Diet
11

12. THOROUGH QUESTIONNAIRE
• Past hospitalizations, operations, traumatic injuries and
serious illness
• Recent minor illness or symptoms
• Medications currently or recently in use and allergies
(particularly drug allergies)

13. •Description of health related habits or addictions, such as the use of
ethanol, tobacco, illicit drugs, amount and type of daily exercise
• Date and result of last medical checkup or physician visit

14. WHY TAKE A COMPREHENSIVE
MEDICAL HISTORY
Many medical problems and/or can affect or influence the
provision of dental care.
Examples:
• Heart disease (infection, bleeding, drug interaction, cause an
Myocardiai Infarction or Angina, oral lesions)

15. • Allergies( reactions to local anaesthetics, antibiotics, analgesics, latex)
• Diabetics (infection, hypoglycemia, periodontal disease)
• Bleeding disorders, drugs induced genetic (abnormal hemostasis)

16. BASIC LIFE SUPPORT
•Primary response to all emergencies.
•P-A-B-C-D
•Position>Airway>Breathing>Circulation>Def
initive medical care
16

17. • POSITION:
The patient should in placed in the supine position. The head and
chest of the patient are placed parallel to the floor and the feet elevated
slightly (10 degrees) to facilitate return of blood from the periphery.

18. • AIRWAY:
Head tilt combine with chin lift may be used to obtain a patient
airway. The clinician places one hand on the patient’s forehead and
other hand to the bony prominence of the chin.
The head is extended backward, stretching the tissue in the neck
and lifting the tongue off the posterior wall of the pharynx.

19. • BREATHING:
While maintaining the head tilt, clinician should places his or her
ear approximately 1 inch from the patient’s mouth and nose so that any
exhaled air from the patient may be felt or heard.
The rescuer looks toward the chest of the patient to see whether
spontaneous respiratory efforts are present.

20. • Circulation:
Clinician should determine if oxygenated blood is circulating to
the tissues and organs in the body, primarily to the brain, which is
composed of cells or neurons that are very sensitive to anoxia.
A large artery must be located and carefully palpated. The
carotid artery is much preferred. It is located in the neck and can be
accessed easily without disrobing the patient.

21. • DEFINITIVE MEDICAL CARE:
Administer oxygen as soon as it becomes available. Whenever
there is a strong suspicion that chest pain is of angina origin, but is likely
to be myocardial infarction, or in the first episode of chest pain the
EMERGENCY MEDICAL SERVICE system should be activated as soon as
possible.

22. CHAIN OF SURVIVAL

23. CARDIOPULMONARY RUSUSCITATION (CPR)
• What Do You Mean By CPR?
It Is A Combination Of Mouth To Mouth Rescue Breathing
And Chest Compressions. It Helps To Keep Blood And Oxygen Circulating
To The Heart And Brain Of A Person Whose Heart Has Stopped Beating.
A person in cardiac arrest has the best chance of survival if
CPR is started immediately and a ‘defibrillator, is used on them as soon
as possible.

24. HOW DO WE PERFORM CPR?
START COMPRESSIONS
• Make sure the person is lying flat on their back.
• Place the heel of your stronger hand on the lower half of the chest
bone.
• Place the other hand securely on top of your stronger hand.

25. • Press down firmly and smoothly, compressing to one-third of the depth
of the chest. Give 30 compressions at a rate of about 2 compressions
each second.
• Try not to interrupt at the time of giving chest compressions

26. START RESCUE BREATHING:
• Make sure that their head is tilted back and their chin is lifted.
• Give 2 rescue breaths, taking about 1 sec. to complete each breath.

27. TO GIVE SOMEONE A RESCUE BREATH:
• Cover their open mouth with your mouth.
• Seal their nose with your cheek or pinch their nostrils with your finger
and thumb until their chest rises.

28. CONTINUE CPR:
• Repeat the cycle of 30 compressions and 2 rescue breaths.
• Keep going until the person starts responding or breathing normally,

29. IF A SECOND PERSON PRESENT, THEY SHOULD:
• Call 102 for ambulance.
• Attach defibrillator if there is available.
• Help you to give person CPR.

30. HELP LINE NUMBERS
• Ambulance Helpline: 102
• Medical Helpline: 108
• People’s medical college
emergency number: 0755-4005200
• Trauma centre : 0755-4040000
(Narmada Trauma Centre)

31. ASA PHYSICAL STATUS CLASSIFICATION
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.
31

32. ASA-I
• The heart, lungs, liver, kidneys, and CNS appear to be in good
health.
• Patient should be able to tolerate the stress involved in a dental
treatment plan without any risk of serious complications.

33. ASA - II
• Well controlled non-insulin dependent diabetes mellitus.
• Well controlled epilepsy.
• Well controlled asthma.
• Well controlled hyperthyroid or hypothyroid disorders.
• ASA-I with upper respiratory tract infections.

34. • Healthy pregnant women.
• Healthy patients with allergies, especially to drugs.
• Healthy patients over 60 years of age.
• Adults with BP between 140 to 159mmHg systolic and/or 90 to
94mmHg diastolic

35. ASA-III
• Stable angina pectoris.
• Status post myocardial infarction more than 6 months before
treatment.
• Status of cardio vascular accident more than 6 months before
treatment.
• Well controlled insulin dependent diabetes mellitus.

36. • Congestive heart failure with orthopnea and ankle edema.
• Exercise induced asthma.
• Hyperthyroid or hypothyroid disorders when patients are symptomatic
• Less well controlled epilepsy.

37. • COPD- emphysema or chronic bronchitis.
• Adults with blood pressure between 160 to 199 mmHg systolic
and/or 95 to 114 mmHg diastolic.

38. ASA-IV
• Unstable angina pectoris (preinfarction angina)
• Myocardial infarction within the 6 months.
• Cardio-vascular accident within the past 6 months.
• Adult blood pressure greater than 200mmHg or 115mmHg

39. • Severe congestive heart failure or COPD
• Uncontrolled epilepsy
• Uncontrolled insulin dependent diabetes mellitus

40. ASA-V
• End stage renal disease.
• End stage hepatic disease.
• End stage cancer.
• End stage infectious disease.
• End stage cardiovascular disease.
• End stage respiratory disease.

41. TYPES OF EMERGENCIES
 UNCONSCIOUSNESS / SYNCOPE
 Vasodepressor Syncope
 Postural/Orthostatic Hypotension
 Acute Adrenal Insufficiency
 Hypoglycemia
 SEIZURES
 RESPIRATORY EMERGENCIES
 Airway Obstruction
 Hyperventilation
 Asthma
41

42.  CARDIOVASCULAR EMERGENCIES
 Angina Pectoris
 Myocardial Infarction
 Heamorrhage
 DRUG RELATED EMERGENCIES
 Overdose Reactions
 Allergies
 FUNCTIONAL EMERGENCIES
 Needle Stick Injury
 Needle Breakage
42

43. • “Sudden transient loss of consciousness in which one shows no
responsiveness to non-deliberate environmental stimuli”
Webster-Merriam’s Medical Dictionary. 12th ed. Baltimore:Williams;2011.“syncope”;p.348
SYNCOPE

44. PRE-DISPOSING FACTORS

45. VASODEPRESSOR SYNCOPE
45
Stress=Tachycardia=Carotid
body & sinus stimulation
Vagal stimulation=
Bradycardia,
Vasodilation=Decreased
cerebral blood flow
Reflexive response to re-
establish cerebral blood
flow=syncope

46. PREVENTION
Via prevention of predisposing factors:
 Adequate air conditioning eliminates heat factor.
 Each patient, especially those who are anxious, should be requested
to eat a light snack or meal before the dental procedure
 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
46

47. MANAGEMENT
ASSESS CONSCIOUSNESS
ACTIVATE OFFICE EMERGENCY SYSTEM
PERFORM BLS
D-INTITIATE DEFINITIVE CARE
ADMINISTER OXYGEN
MONITOR VITAL SIGNS
PERFORM ADDITIONAL PROCEDURES
ADMINISTER AROMATIC AMMONIA
ADMINISTER ATROPINE IF BRADYCARDIA PERSIST
MAINTAIN COMPOSER
POSTSYNCOPAL RECOVERY DELAYED RECOVERY
POSTPONED FURTHER DENTAL TREATMENT ACTIVATE EMERGENCY MEDICAL SERVICES
DETERMINE PRECIPITATING FACTORS

48. POSTURAL /ORTHOSTATIC
HYPOTENSION
It is defined as a disorder of the autonomic nervous system in
which syncope occurs when the patient assumes an upright
position.

49. 49
Pt attains upright
position
Systolic BP falls =<60mm
of Hg due to ANS response
failure
Cerebral blood
flow<critical level
Loss of consciousness
Supination=revival
PATHOLOGY
Drugs
• Adrenergic blockers
• Calcium channel blockers
• Diuretics
• Vasodilators
• Centrally acting
antihypertensive
Prolonged recumbency /
convalescence
Late stage pregnancy
Varicosities
Addison’s Disease
Severe exhaustion
Shy-Drager Syndrome
ETIOLOGY

51. MANAGEMENT
ASSESS CONSCIOUSNESS
ACTIVATE OFFICE EMERGENCYSYSTEM
P- POSITION PATIENT SUPINE WITH FEET SLIGHTLY ELEVATED
A-B-C- ASSESS AND OPEN AIRWAY, ASSESS BREATHING AND CIRCULATION
D-INITIATE DEFINITIVE CARE
ADMINISTER OXYGEN
MONITOR VITAL SIGNS
EPISODE TERMINATES EPISODE CONTINUES
PROVIDE SUBSEQUENT MANAGEMENT SUMMON MEDICAL ASISTANCE
SLOWLY REPOSITION CHAIR
DISCHARGE PATIENT

52. ACUTE ADRENAL INSUFFICIENCY
52
Cause1
• Sudden supplement withdrawal in Addison’s disease
patients.
Cause2
• Stress, either physiological or psychological.
Cause3
• Bilateral adrenalectomy patients.
Cause4
• Trauma/thrombosis/tumour of adrenals
Syncope caused due to lack of an adrenaline response in
medullary deficient patients resulting from:-

53. HYPOGLYCEMIA
53
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

54. MANAGEMENT
CONSCIOUS PATIENT
TERMINATE DENTAL TREATMENT
P-POSITION PATIENT COMFORTABLY, IF ASYMPTOMATIC
SUPINE WITH FEET ELEVATED SLIGHTLY, IF SYMPTOMATIC
A-B-C- PROVIDE BASIC LIFE SUPPORT, AS NEEDED
D- DEFINITIVE CARE
MONITOR VITAL SIGNS
SUMMON MEDICAL ASSISTANCE
OBTAIN EMERGENCY KIT AND OXYGEN
ADMINISTER GLUCOCORTICOSTEROID, IF AVAILABLE,
AND IF HISTORY OF ADRENAL INSUFFICIENCY EXISTS
CONSIDER ADDITIONAL MANAGEMENT, AS NEEDED
PROVIDE OXYGEN, AS NEEDED
PROVIDE GLUCOCORTICOSTEROID, AS NEEDED
ESTABLISH i.v LINE

55. UNCONSCIOUS PATIENT
RECOGNIZE UNCONSCIOUSNESS
P- POSITION PATIENT SUPINE WITH FEET ELEVATED SLIGHTLY
A-B-C- PROVIDE BASIC LIFE SUPPORT
D- DEFINITIVE CARE
OBTAIN EMERGENCY KIT AND OXYGEN
SUMMON MEDICAL ASSISTANCE
EVALUATE MEDICAL HISTORYV
ADMINISTER GLUCOCORTICOSTEROID
ESTABLISH i.v LINE, IF POSSIBLE
TRANSFER TO HOSPITAL

56. SEIZURES

57. EPILEPSY
 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”
 Epilepsy is recognized when a prson has 2 or more unprovoked seizures
Webster-Merriam’s Medical Dictionary. 12th ed. Baltimore:Williams;2011. “Epilepsy”, “Seizure”, “Tonus”; p166,327,428
57

58. ASA CLASSIFICATION OF
EPILEPTIC SEIZURES
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
58
78%
11%
3%
4.8%
1%
2.2%

59. PREVENTION
If patient 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 individualized severity levels.
Keep life support equipment ready in case of an emergency.
59

60. MANAGEMENT
Self limiting emergency
Remove dangerous objects from the mouth and around the pateint.eg. sharp
instruments, needles, etc.
Loosen any tight clothing.
Avoid restraining the patient.
In case the ictus fails to subside within a maximum of 10 minutes, declare status
epilepticus and proceed with BLS + definitive care.
60

61. RESPIRATORY
EMERGENCIES
61

62. AIRWAY OBSTRUCTION
 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
62

63. PREVENTION
Rubber dam
Ligature
Suction
Oral packing
Chair position
Dental assistant
Magill’s intubation forceps 63

64. ASSESS UNRESPONSIVENESS
P-POSITION VICTIM IN SUPINE POSITION WITH FEET ELEVATED
CALL FOR HELP(OFFICE EMERGENCY TEAM)
A-OPEN AIRWAY (HEAD TILT – CHIN LIFT TECHNIQUE)
B- ASSESS BREATHING (LOOK, LISTEN, FEEL)
ATTEMPT TO VENTILATE
IF UNSUCCESSFUL, REPOSITION HEAD AND ATTEMPT TO VENTILATE
IF STILL UNSUCCESSFUL, ACTIVATE EMERGENCY MEDICAL SERVICES SYSTEM
MANAGE AIRWAY OBSTRUCTION
CHECK PULSE
PERFORM EXTERNAL CHEST COMPRESSION, IF NECESSARY

65. HYPERVENTILATION
 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.
65

66. Anxiety
Increased rate and depth of
respiration
Increased O2/CO2 exchange by
lungs
Excessive CO2 blow off>>paCO2
decreases
Hypocapnia=decreased
bionarbonate ion conc.
Increased blood
pH>>RESPIRATORY ALKALOSIS
PATHOLOGY
Terminate dental procedure
P- position patient comfortably usually upright
A-B-C- basic life support, as needed
D-definitive care
Remove dental material from patien’s mouth
Calm patient
Correct respiratory alkylosis
Initiate drug management if necessary
Perform subsequent dental treatment
Discharge patient
MANAGEMENT
66

67. 67

68. ASTHMA
 A clinical state of hyper reactivity of the tracheobronchial tree,
characterized by recurrent paroxysms of dyspnea and wheezing
 In diagnosed patients, not an emergency.
 Results from constriction of smooth muscles of the tracheobronchial
tree resulting from infection, inflammation or a genetic disposition.
68

69. Predisposing factors-INTRINSIC & EXTRINSIC
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
69

70.  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.
70
INTRINSIC OR IDIOSYNCRATIC OR NON-ATOPIC
ASTHMA

71. MANAGEMENT
71
Recognise symptoms
Stop dental procedure
Position patient upright or bending forwards with
arms straight ahead
Administer bronchodilator
Episode terminates?
YES NO
Continue dental procedure Declare status asthmaticus
Summon Emergency Medical Support

72. REFERENCES
 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
72

73.  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
73

76. MANAGEMENT OF
MEDICAL EMERGENCIES IN
DENTAL PRACTICE
Presented by:
Dr. AKANKSHA NARELA

77. CONTENTS
PART – 2
TYPES OF EMERGENCIES:
•CARDIOVASCULAR EMERGENCIES
Angina Pectoris
Myocardial Infarction
Hemorrhage

78. •DRUG RELATED EMERGENCIES
Overdose Reactions
Allergies
•FUNCTIONAL EMERGENCIES
Needle Stick Injury
Needle Breakage
EMERGENCY DRUG KIT
REFERENCES

79. CARDIOVASCULAR
EMERGENCIES
79

80. 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
80

81. ANGINA PECTORIS
Definition- “A condition marked by severe pain in the chest, often also
spreading to the shoulders, arms, and neck, owing to an inadequate
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 81

82. 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 Emergency Medical System
Transmucosal nitroglycerine spray O2 and nitroglycerine
Or sublingual nitroglycerine tablet Monitor and record the vital signs
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
82
MANAGEMENT

83. MYOCARDIAL INFARCTION
 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
83

84. DENTAL CONSIDERATIONS
 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 Nerve Block and Posterior superior alveolar Nerve Block –
risk of hemorrhage – should be avoided
84

85. MANAGEMENT
Protocol common for both Acute Coronary Syndrome 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
Angina Pectoris.
85

86. HEMORRHAGE

87. HEMORRHAGE
• Prolonged or uncontrolled bleeding is often referred to as
hemorrhage.
• The amount of blood lost as a result of hemorrhage can range
from minimal to significant quantities.
• Hemorrhage can occur to a greater or lesser degree during all
surgical procedures and it’s management depends upon whether the
patient is hematologically normal or suffers from some disturbance in
the normal clotting mechanism.

88. • The overwhelming majority of patients who undergo oral surgical
procedures are those who have normal haemostatic mechanism.
• Therefore, significant or major hemorrhages are not that common
except in patients who have a bleeding / clotting disorder or those who
are on anticoagulants.
• Hence, it is still important to achieve proper hemostasis in all patients
during oral surgical procedures, so as to prevent excessive post-
operative blood loss.

89. DIFFICULTIES IN THE
MANAGEMENT OF A HEMOPHILIAC DENTAL
PATIENT INCLUDE THE FOLLOWING:
• Dental neglect necessitating frequent extractions
• Trauma and surgery
• Factor VIII inhibitors
 Hazards of anesthesia and injections
 Risk of hepatitis B and liver disease and HIV infection
Scully C, Cawson RA. Medical problems in dentistry. 5th ed. Elsevier: London; 2005.

90. • Aggravation of bleeding by drugs
• Anxiety and drug dependence
• The bleeding tendency can be aggravated by NSAIDs. Safer alternatives for pain
control are acetaminophen, codeine and Cox-2 inhibitors.
• Local anesthetic regional blocks, lingual infiltrations or injections into the floor of
the mouth must not be used in the absence of Factor VIII replacement because of
the risk of hemorrhage hazarding the airway and being life-threatening. If FVIII
replacement therapy has been given, regional LA can be used . And FVIII level is
maintained above 30%.
Scully C, Cawson RA. Medical problems in dentistry. 5th ed. Elsevier: London; 2005.

91. MANAGEMENT OF HEMORRHAGE
IN NORMAL PATIENTS
The management of bleeding during surgery (Primary bleeding) can be achieved by
the following means,
• Securing / ligation of blood vessels with silk sutures.
• Use of pressure swab to achieve hemostasis.
• Use of electrocautery to achieve hemostasis.
• Use of hemostatic agents like bone wax, surgicel,e.t.c.,
• Hypotensive anaesthesia (G.A) and use of vasoconstrictors in L.A.

92. LOCAL MEASURES
( SYNTHETIC MATERIALS)
There are several materials that are commercially available that are
used locally for achieving adequate homeostasis'.
Surgicel (Oxidized Regenerated Cellulose)
Gelfoam with activated thrombin
Avitene (Microfibrillar Collagen)

93. Etik Collagen (Packed collagen)
Tranexamic acid 5% in syringe
Irrigation of wound with Tranexamic
Suturing the wound.
Pressure with oral packs

94. MANAGEMENT OF
HEMORRHAGE IN PATIENTS WITH BLEEDING
DISORDERS / AND THOSE ON
ANTICOAGULANT THERAPY
The usual protocol involved in the treatment of this group of patients
consists of pre-operative blood investigations and preoperative correction
of the underlying deficiency (Replacement of Clotting factors / platelets) if
any in these patients.
Subsequently, after this appropriate local measures are used to decrease
the chances of post-operative bleeding.

95. DRUG RELATED
EMERGENCIES
95

96. OVERDOSE REACTIONS
 In a dental practice, commonest over dosage>>LA
 Predisposing factors for over dosage:
 Patient age/body weight
 Route of administration
 Presence of vasoconstrictor
 Type of local anesthetic
 Drug dosage formula:
96
D
H
X

97. CLINICAL MANIFESTATIONS
 Confusion, talkativeness, blurred speech
 Muscular twitching, facial tremor
 Headache, tinnitus
 Drowsiness, disorientation
 Elevated Blood Pressure, Heart Rate, Respiratory Rate
 If uncontrolled, generalized tonic clonic seizures, generalized Central
Nervous System carbopathy.
97

98. MANAGEMENT
Administer basic life support
100% oxygen, anticonvulsants
Allow recovery to occur
In case of continuation of symptoms, summon Emregency
Medical System. 98

99. ALLERGY
 DEFINITION- “A hypersensitive state of skin and various mucosa
acquired through exposure to a particular allergen, re -exposure to which
produces a heightened emergent capacity to react”
 Occurring via expression
of IgE in response to
allergen exposure
99

100. Signs and Symptoms of an Allergic Reaction
 Cutaneous reactions are the most common occurrence and include
urticarial, exanthematous, and eczemoid reactions. Itching is common
and can also find exfoliative dermatitis and bullous dermatosis.
 Angioedema (Swelling) this varies from localized slight swelling of the
lips, eyelids, and face to more uncomfortable swelling of the mouth,
throat, and extremities.

101.  Respiratory (Tightness in chest, sneezing, bronchospasm)
bronchospasm is a generalized contraction of bronchial smooth muscles
resulting in the restriction of airflow. This may also be accompanied by
edema of the bronchiolar mucosa. Bronchospasm is more common with
pre-existing pulmonary disease such as asthma or infection but can also
be caused by the inhalation of a foreign substance.
 Ocular reactions include conjunctivitis and watering of eyes.
 Hypotension can occur with any allergic reaction.

102. ANAPHYLAXIS:
Signs and symptoms include:
 Cardiovascular shock including; pallor, syncope, palpitations,
tachycardia, hypotension, arrythmias, and convulsions.
 Respiratory symptoms include; sneezing, cough, wheezing, tightness in
chest, bronchospasm, laryngospasm.
 Skin is warm and flushed with itching, urticaria, and angioedema.
 Nausea, vomiting, abdominal cramps, and diarrhea also possible.

103. ABC’s
Maintain airway, administer oxygen, and determine possible need for
intubation or surgical airway.
Monitor vital signs.
If in shock put patient in a horizontal or slight Trendelenburg position.
TREATMENT
GENERAL TREATMENT

104. MILD REACTIONS
Antihistamines usually effective. (Benadryl 50-100mg or Cholpheniramine maleate 4-12
mg IV, or IM.)
Identify and remove allergen.
Follow up medications in 4-6 hours.
SEVERE REACTIONS
If available start IV Fluids
Epinephrine is drug of choice. Usually prepackaged 1:1,000 in 1mg vials or syringe
104

105. If IV in place titrate 1:1,000 solution to effect.
If drop in blood pressure is minimal, start with 0.5ml (0.5mg.)
If drop in blood pressure is severe start with 2ml (2mg.)
Repeat after 2 minutes if needed.
If no IV use 1:1,000 (1mg/CC) IM 0.3 to 0.5mg (0.3-0.5CC.)
For an adult repeat this dose in 10 to 20 minutes.

106. If the patient is intubated can give epinephrine endotracheally
If Asthma, edema, or pruritis (Itching) are present can use Corticosteroids.
However these drugs are to slow acting to be used for an emergency situation.
Hydrocortisone sodium succinate (Solu-cortef) 100-500mg IV or IM.
Dexamethasone (Decadron) 4-12mg IV or IM.
Repeat dose at 1, 3, 6, and 10 hours as indicated by severity of symptoms.
106

107. 107
OTHER CONSIDERATIONS
Monitor and record vital signs.
Seizures are possible as a result of circulatory or respiratory
insufficiency.
Most severe allergic reactions require hospitalization and
observation for 24 hours.

108. EMERGENCY DRUG KIT
108
GLUCERIN TRINITRATE (GTN)
SPRAY
SALBUTAMOL AEROSOL INHALER
(100mcg)
ADRENALINE PRE-FILLED
SYRINGE (1:1000, 1mg/ml)
GLUCAGON INJECTION (1mg)
ASPIRIN DIPERSABLE (300mg)
ORAL GLUCOSE GEL
MIDAZOLAM(10mg) BUCCAL

109. GLYCERYL TRINITRATE SPRAY
• Glyceryl Trinitrate Spray is a smooth muscle relaxant.
• When you this spray under your tongue it is quickly absorbed in the
bloodstream.
• The action of Spray allows blood to flow more quickly and more easily.
This means that your heart does not need to work so hard.

110. • The greater blood flow through the heart also means that the heart
works more efficiently.
• These actions of this bring relief in an attack of angina and can prevent
an attack coming on.
• Commercial name: ANRIL (400 mcg)

111. SALBUTAMOL INHALATION AEROSOL
• This is used to treat or prevent bronchospasm in patients with asthma,
bronchitis, emphysema, and other lung diseases. This medicine is also
used to prevent wheezing caused by exercise (exercise-induced
bronchospasm).
• It belongs to the family of medicines known as adrenergic
bronchodilators.

112. • Adrenergic bronchodilators are medicines that are breathed in
through the mouth to open up the bronchial tubes (air passages) in
the lungs.
• They relieve cough, wheezing, shortness of breath, and troubled
breathing by increasing the flow of air through bronchial tubes.
• Commercial name: ALBUTEROL

113. ADRENALINE (EPINEPHRINE) INJECTION
1:10,000
• Adrenaline (Epinephrine) belongs to a group of medicines used for the
treatment of serious shock produced by a severe allergic
(hypersensitive) reaction or collapse
• It may also be used to restart your heart if it has stopped.
• Route of administration: Injection 1:10,000 to you either into a vein
(intravenous) or into a bone (intraosseous).

114. • Adults and children over 12 years: In heart resuscitation, the
recommended dose is 1mg into the vein.
• Children under 12 years:10 micrograms per kilogram of body weight,
repeated every 3-5 minutes.

115. GLUCAGON INJECTION
• Glucagon belongs to the group of medicines called hormones. It is an
emergency medicine used to treat severe hypoglycemia (low blood
sugar) in patients with diabetes who have passed out or cannot take
some form of sugar by mouth.
• Glucagon is also used during x-ray tests of the stomach and bowels to
improve test results by relaxing the muscles of the stomach and
bowels. This also makes the testing more comfortable for the patient.

116. • If the person with diabetes is unconscious, give them the glucagon
shot, then immediately call other emergency services. If
emergency services have not arrived within 5 minutes and the
person is still unconscious, give another glucagon shot.

117. ASPIRIN
• There is strong evidence that aspirin, taken during a heart attack, can
reduce the size of the thrombus (clot) causing the attack and may even
cause the platelets in the clot to disperse.
• Aspirin also has effects on processes other than clotting, suggesting
that if taken very early in an attack, the damage to the heart could be
reduced and additional lives saved.

118. • Patients known to be at risk of a heart attack, including all persons over
about 50 years of age, would be well advised to carry a few tablets of
soluble aspirin at all times, and chew and swallow a tablet
immediately, if they experience severe chest pain, even as they are call
102
• IMPORTANT NOTE: IF YOU NEED TO TAKE AN EMERGENCY DOSE OF
ASPIRIN YOU MUST DIAL 102 FOR AN AMBULANCE FIRST – AND THEN
IMMEDIATELY CHEW AND SWALLOW ONE 300mg SOLUBLE ASPIRIN. If
In Doubt Speak To Your Doctor!

119. GLUCOSE GEL
Glucose gel is used for:
• Treating reactions caused by low blood glucose (sugar).
• Glucose gel is a monosaccharide (simple sugar). It works by quickly
raising the glucose level in the blood.
• Subcutaneous glucagon may be easier to administer than oral or
intravenous glucose.

120. MIDAZOLAM
• Buccal Midazolam 10mg/ml is an effective, more socially acceptable
and well-tolerated alternative to Rectal Diazepam .
• Licenced Indication Epistatus® is an ‘specials’ preparation
manufactured specifically for buccal management of epileptic seizures.
• It contains 10mg/ml midazolam formulated in a sugar free syrup and is
supplied as a bottle containing 5ml with four oral 1ml syringes.

121. • This drug is used as required for prolonged e.g. longer than 5 or 10
minutes, convulsive epileptic seizures. It is also used for a prolonged
series of epileptic seizures continuing for 5 or 10 minutes or more
without the patient waking up and coming round in between.
• Dose: for children: between 0.3-0.5 mg/kg up to a maximum single
dose of 10 mg
Adult:10 mg doses

122. FUNCTIONAL
EMERGENCIES
122

123. NEEDLE STICK INJURY
 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. 123

124. NEEDLE BREAKAGE
 Invariably associated with faulty techniques such as:
 bending the needle while administering Local Anaesthesia
 inserting the needle upto the hub
 directing the needle against resistance
 May also occur if patient jerks head during administration.
 Most commonly with Infra Alveolar Nerve Block.
 Elasticity of soft tissue produces rebound, burying the fragment within.
124

125. MANAGEMENT
Inform patient 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.
125

126. SUMMARY & CONCLUSION
 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.
126

127. REFERENCES
 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
127

128.  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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