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Medical emergencies in dental practices
- 1. Ā©M. S. Ramaiah University of Applied Sciences
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Ā©M. S. Ramaiah University of Applied Sciences
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MEDICAL EMERGENCIES IN DENTAL
PRACTICE
DR SEJAL K M
READER
DEPTOF ORAL& MAXILLOFACIAL SURGERY
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MEDICALEMERGENCIES
Goldberger 1990, āWhen you prepare for an emergency,
the emergency ceases to exist.ā
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CLASSIFICATION OF LIFETHREATENING EMERGENCIES
ā¢ UNCONSCIOUSNESS
ā VasodepressorSyncope
ā Postural Hypertension
ā Acute Adrenal Insufficiency
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CLASSIFICATION OF LIFETHREATENING EMERGENCIES
ā¢ RESPIRATORY DISTRESS
ā Foreign Body Airway Obstruction
ā Hyperventilation
ā Asthma
ā Myocardial Infarction or Angina
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CLASSIFICATION OF LIFETHREATENING EMERGENCIES
ā¢ ALTERED CONSCIOUSNESS
ā Diabetes Mellitus: Hyperglycemia and Hypoglycemia
ā Cerebro vascular Accident
ā¢ SEIZURES
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CLASSIFICATION OF LIFETHREATENING EMERGENCIES
ā¢ DRUG RELATED EMERGENCIES
ā Drug OverdoseReactions
ā Allergy
ā¢ CHEST PAIN
ā Angina Pectoris
ā Acute Myocardial Infarction
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ANXIETY
Symptomsofanxietydisorderinclude:
ā¢ Feelingsofpanic,fear, anduneasiness.
ā¢ Problemssleeping.
ā¢ Coldor sweatyhandsand/orfeet.
ā¢ Shortnessofbreath.
ā¢ Heartpalpitations.
ā¢ Aninabilitytobestillandcalm.
ā¢ Drymouth.
ā¢ Numbnessor tinglinginthehandsor feet.
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SYNCOPE
ļ§ Vasovagal syncope
ļ§ Simple faint is the most common medical emergencyseen in dental
practice.
ļ§ Loss of consciousness duetoinadequate cerebral perfusion
ļ§ Mediated by autonomic nerves.
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SYNCOPE
ā¢ Fainting can beprecipitated by
Psychogenicfactors
ā¢ Fright
ā¢ Anxiety
ā¢ Emotional stress
ā¢ Receipt of unwelcome news
ā¢ Pain especially sudden &unexpected
ā¢ Sight of blood/ surgical/ dental instruments
ā¢ (e.g.local anesthetic syringe)
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Non psychogenicfactors
ā¢ Erect sitting orstanding posture
ā¢ Hunger from dieting or a missed meal
ā¢ Exhaustion
ā¢ Poor physical condition
ā¢ Hot, humid, crowded environment
ā¢ Male gender
ā¢ Agebetween 16 and 35 years
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ā¢ Warm feeling in face and neck.
ā¢ Pale orashen coloration.
ā¢ Sweating.
ā¢ Feels cold.
ā¢ Abdominal discomfort, Nausea and/or vomiting;
ā¢ Lightheaded ordizziness.
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ā¢ Mydriasis (Pupillary dilatation.)
ā¢ Yawning.
ā¢ Increased heartrate initially later bradycardia
ā¢ Steady orslight decrease in blood pressure.
ā¢ Seizures
ā¢ Loss ofconsciousness
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Stress
Catecholamines release
peripheral vascular resistance & āblood flow to peripheral muscles
āvenous return
ācirculatory blood vol. & fall in arterial B.P.
Reflux bradycardia develops (< 50)
Significant drop in cardiac output associated with fall in B.P below the critical
level
Cerebral ischemia & loss of consciousness
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ļ§ Treatment for fainting involves the following:
1. Lie the patient flat and raise the legs trendlenburgposition.
2. A patent airway must be maintained.
3. If recoveryis delayed, oxygen (10litres) should beadministered.
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SYNCOPE
ā¢ Aromatic ammonia has a noxious odour and irritates the mucous
membranes of the upper respiratory tract, stimulating the respiratory and
vasomotor centres of the medulla. This action in turn increases
respiration andblood pressure.
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HYPERVENTILATION
ā¢ It is defined as ventilation in excess of that required to maintain normal
blood pa O2 (arterial oxygen tension) and pa CO2 (arterial carbon
dioxide tension).
ā¢ Thereis increase in frequency ordepth of respiration, orboth.
ā¢ Commonest emergency in dental office always occurs as a result of
extremeanxiety.
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Anxiety
Increased rateand depth of respiration
āexchangeof O2 & CO2 by lungs
ā blowing off of CO2 and paCO2 decreases
Hypocapnia
āin blood pH
Respiratory alkalosis
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Recognizeproblem (rapid , deep,uncontrolled breathing)
P āPosition patient comfortably, usually upright
A ā BāCāBasic life support as needed
D āDefinitive care:
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ļ Prevention:
Through prompt recognition and management of anxiety.
Stress reduction protocol is the primary means of preventing
hyperventilation.
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ā¢ Removedental materials from patientās mouth
ā¢ Calm patient
ā¢ Correctrespiratoryalkalosis ā instructed to breathe 7% CO2 & 93% O2
orto rebreathe the exhaled air.
ā¢ Initial drug management āBenzodiazepines
ā¢ Dental caremay continue if both doctor and patient agree
ā¢ Discharge patient
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STROKE
Stroke:
ā¢ Stroke may beeither hemorrhagic orembolic.
ā¢ Signs and symptoms varyaccording to the site of brain damage.
ā¢ Loss of consciousness andweakness of limbs on one side of the body.
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ā¢ Oneside of the face may becomeweak.
ā¢ As stroke causes an upper motor neuron lesion, the forehead muscles of
facial expression will be unaffected.
ā¢ Speechmay becomeslurred.
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Initialmanagement ofa stroke includes the following:
ļ¼ Theairway should be maintained and anambulance called.
ļ¼ High flow oxygen (10litres perminute) should begiven.
ļ¼ The patient should be carefully monitored for any further
deterioration.
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HYPOGLYCEMIA
ļ§ Theproper casehistory- diabetic control.
ļ§ Varying blood glucose levels- hypoglycaemia.
ļ§ Treat them during morning appointment.
ļ§ Medication and food prior to appointment.
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HYPOGLYCEMIA
ā¢ Thesigns and symptoms of hypoglycemia include:
ļ¼ Trembling
ļ¼ Hunger
ļ¼ Headache
ļ¼ Sweating
ļ¼ Slurring of speech
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HYPOGLYCEMIA
ļ¼ āPins and needlesā in lips and tongue
ļ¼ Aggression and/or confusion
ļ¼ Seizures
ļ¼ Unconsciousness.
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Management of Hypoglycemia
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Management of Hypoglycemia
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ANAPHYLAXIS
ā¢ āThesigns and symptoms of anaphylaxis include:
ļ§ āItchy rash/erythema.
ļ§ Facial flushing orpallor.
ļ§ āUpper airway (laryngeal) oedema and bronchospasm leading to
stridor, wheezingand, possibly, hoarseness.
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Management of Anaphylaxis
ā¢ Diphenhydramine Hydrochloride (Avil)
ā¢ 1:1000 Adrenaline
ā¢ Hydrocortisone 100mg
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ANAPHYLAXIS
Initial treatment for anaphylaxis includes thefollowing:
ā¢ āThe ABC approach should be employed while the diagnosis is being
made.
ā¢ Airway and breathing should be managed by administering 10
litres/min of oxygen.
ā¢ Blood pressure should berestored by lying the patient flat.
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ā¢ In life-threatening anaphylaxis (hoarseness, stridor, cyanosis, dyspnoea,
drowsiness, confusion or coma), adrenaline should be administered in the
following way.
ā¢ āAdminister 0.5 ml of 1 in 1000 adrenaline (epinephrine) IM and repeat
at 5minute intervals if no improvement.
ā¢ Theoptimum site for injection is the anterolateral mid-third of the thigh.
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ADRENAL CRISIS
Adrenalcrisis:
ā¢ It may result from adrenocortical hypofunction leading to hypotension,
shock anddeath.
ā¢ It maybe precipitated by stressinduced by trauma, surgery orinfection.
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Thesigns and symptoms of adrenal crisis include:
ā¢ āThe patient loses consciousness.
ā¢ āThe patient has a rapid, weak orimpalpable pulse.
ā¢ āThe blood pressure falls rapidly.
ā¢ It is important in the history to ascertain whether the patient has recently
used oris currently using corticosteroids.
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ADRENAL CRISIS
ā¢ Acute adrenal insufficiency can often be prevented by the administration
of a steroid boost prior to treatment.
ā¢ Ruleof 2
ā¢ Invasive procedure such as oral surgical procedures or very
apprehensive patients, may requirecover.
ā¢ Patients who are systemically unwell (for eg. patients with a dental
abscess) arealso recommended.
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Thetreatment of adrenal crisis includes the following:
ā¢ āLay the patient flat andraise his/her legs.
ā¢ āEnsure a clearairway andadminister oxygen.
ā¢ āCall anambulance.
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ANGINA / MYOCARDIAL INFARCTION
ā¢ Moderate to crushing central chest pain, radiating to left arm, neck or
mandible.
ā¢ Stop treatment, place one glyceryl trinitrate tablet 0.6 mg under tongue
orspray under tongue.
ā¢ Repeat dose in 5 minutes.
ā¢ If noimprovement after 15 minutes,
treat asacute myocardial infarction.
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Signs &Symptoms ofMyocardial Infarction
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MYOCARDIAL INFARCTION
ā¢ Chest pain similar to angina but unrelieved by up to 3 glyceryl trinitrate
tablets over10minutes.
ā¢ Call for medical help.
ā¢ Monitor vital signs.
ā¢ 100% oxygen.
ā¢ Dissolved aspirin tablet and one glyceryl trinitrate dose stat and one
repeat in 5minutes after checkof BP.
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SEIZURES
ā¢ Abnormalbrainactivity
ClinicalFeatures:
ļ¼ Aura
ļ¼ Tremors
ļ¼ Confused
ļ¼ Sleepy
ļ¼ Trancelikestate
ļ¼ Frothing
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ASTHAMA
ā¢ It is defined as āa chronic inflammatory disorder that is
characterized by reversible obstruction of the
airways.ā
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Status asthmaticus:
ā¢ More severeclinicalform
ā¢ Experiencewheezing,dyspnea,hypoxia
ā¢ Refractoryto2ā3dosesof Ī²-adrenergicagents
ā¢ Ifnotmanagedadequately,patientmay dieduetorespiratory
distress
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Prevention:
Medical history regarding
ā¢ Lung diseases
ā¢ Allergies to drugs, food, medication, latex
ā¢ Usage of drugs, medications, natural remidies
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Clinical manifestations:
ā¢ Feeling of chest congestion
ā¢ Cough, with orwithout sputum production
ā¢ Wheezing
ā¢ Dyspnea
ā¢ Patient wants to sit orstand up
ā¢ Use of accessory muscles of respiration
ā¢ Increased anxiety and apprehension
ā¢ Tachypnea (>20 - >40 in severecases)
ā¢ Rise in B.P, Increase in heartrate (>120 bpm in severecases)
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Onlyin respiratory distress
ā¢ Diaphoresis
ā¢ Agitation
ā¢ Somnolence
ā¢ Confusion
ā¢ Cyanosis
ā¢ Supraclavicular and intercostal retraction
ā¢ Nasal flaring
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Recognizeproblem (respiratory distress, wheezing)
Discontinue dental treatment
Activate office emergencyteam
P āPosition, usually upright with armsthrown forward
A ā Bā CāAssess and perform basic life support as needed
D āDefinitive care:
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Administer O2 and bronchodilators
(Episode continues)
Activate EMS
Dischargepatient
Administer parenteral drugs May
require hospitalisation
(Episode terminates) Dental
care may continue Discharge
patient
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Additional considerations:
Sedatives which depress respiratory system and central nervous system are
absolutely contraindicated. 5mg IV or IM diazepam may be indicated to
decrease anxiety
Editor's Notes
- Penicillin prescribed to allergic patient- error