Medical emergencies in a dental clinic


Published on

medical emergencies in dental clinic

Published in: Health & Medicine
  • Be the first to comment

No Downloads
Total views
On SlideShare
From Embeds
Number of Embeds
Embeds 0
No embeds

No notes for slide

Medical emergencies in a dental clinic

  2. 2. • Its a rare occurrence and managing it can be frightening experience • The doctor and the staff should be adequately prepared. Otherwise the result would be a catastrophe • Simple preventive measures can prevent medical emergencies • A thorough medical history should be taken • If any doubt exists regarding the medical status of the patient the patients physician should be contacted, and a letter or note concerning the patients medical status should be taken and the condition should be stabilized before any elective procedure is to be carried out.
  3. 3. • During any procedure, the doctor and the surgical team should observe the patient carefully if any medical emergencies arise, it should be managed by the doctor and his staff who is well trained in giving CPR and life saving medications. • Drugs and equipments should be checked periodically to ensure that the drugs are not outdated and that the equipments are functioning properly • Emergency numbers should always be within reach.
  4. 4. The emergency medicines to be kept in a dental clinic includes • Oxygen • Aromatic ammonia • Nitroglycerine tablets • Diphenhydramine • Atropine, 0.5mg/ml vial • Epinephrine • Vasopressors – Phenyephrine 10m/ml – Methoxamine. 10mg/ml or 20mg/ml – Norepinephrine, 0.2%, 4 ml ampule – Ephedrine, 50mg/ml – Mephenteramine15mg/ml – mataraminol
  5. 5. • Sodium bicarbonate • Calcium chloride • Lidocaine • Isoproterenol, 1mg ampule • Morphine, 8mg/ml • Meperidine • Steroids – Methylprednisolone sodium succinate – Hydrocortisone sodium succinate • Procaine • Naloxone • Diazepam • Aminophylline
  6. 6. • Sugar – Sugar cubes or small packages – Dextrose, 50% or 50ml vial • Glucagon 1mg dry powder with 1ml dilutent • Succinylcholine chloride • Sterile water for injection
  7. 7. Emergency equipment • Equipment to administer oxygen • Oropharyngeal airways • Endotracheal tubes and connectors • Laryngoscope and blades • Suction catheter • Tonsillar suction tip and hose • Cricothyroid cannula • Scalpel blades and handle • Needles- 22,25 gauges, butterfly(19, 21) & angiocath
  8. 8. • Syringes-1ml, 5ml, 10ml, 50ml • IV fluid(5% D/W, 5% D/S, LR) and administration set • Tourniquet • Stethoscope • Sphygmomanometer • Hemostats • Padded tongue blades • Tape • K-Y jelly • Alcohol sponges
  9. 9. Latest emergency drugs4
  10. 10. Syncope • Transient loss of consciousness secondary to cessation or decreased cerebral blood flow-wintrobe1974 • Most common untoward reaction in dental clinics-ADA1975 • More prevalent in young people and highest incidence in men under 35years- hannington kiff 1969 • Common predisposing factor includes pain, anxiety, sight of blood, physical and mental exhaustion, hot environment, debility, fasting and minor surgical procedures-chue 1975 • These factors trigger a vasodepressor action, with dilation of blood vessels in the skeletal muscles and the splanchnic region • A fall in the peripheral resistance with decreased venous treturn to the heart results, leading to a fall in arterial pressure
  11. 11. • Vagal reflexes are activated, causing bradycardia, a reduction in the cardiac output, and a further reduction in the blood pressure, all leading to decreased cerebral perfusion • Always preceded by prodrome lasting from secs to mins during which the patient has feeling of warmth, weakness, possible epigastric discomfort or nausea and general sense of being feeling badly • Then patient develop sweating, pallor, coldness of the extremities and dizziness, with slight increase in pulse and BP • If not treated promptly it will lead to marked ashen gray pallor, shallow respirations, slow and weak pulse, low BP and dilated pupils
  12. 12. Treatment: • Place the patient in supine position with legs elevated to increase venous return to the heart • Tight constricting clothing should be loosened • A patent airway should be maintained – Remove foreign bodies from the mouth – Suctioning of excess salivary secretions – Bringing the lower jaw forward – Insert oropharygeal airway • Administer oxygen if patient is cyanotic-chue 1975 • Routine use of oxygen in syncope-campbell et al 1976
  13. 13. • Check vital signs • BP and pulse for several mins, adjunctive therapy should be started • Still low along with bradycardia, atropine (0.4mg IV) • If hypotension without bradycardia, then vasopressor such as phenylephrine(2-5mg IV) or methoxamine HCl(5mg IV/15mg IM) should be used • After recovery, patient should be brought out of the supine position very slowly
  14. 14. Prevention- • Always try to keep the patient in a supine or somewhat reclining position during treatment • Relieve fear and anxiety • Good pain control
  15. 15. Hyperventilation • An ↑ in alveolar ventilation caused by abnormally rapid and deep breathing • The form commonly seen in the dental office is the hyperventilation syndrome usually caused by fear and anxiety • Not common occurrence • Precipitated by anxiety, fear, excitement, nervousness, emotional stress and psychoneurotic reactions • Most common in women who are somewhat anxious and nervous • It causes hypocapnia- rotsztain and co workers, 1970 • It cause reduction in the cerebral blood flow and resp. alkalosis
  16. 16. • Respiratory alkalosis favors a reduction in the calcium levels leading to muscular spasms and symptoms suggestive of tetany- seamonds et al, 1972 • Recognition – Dizziness and difficulty in breathing – Palpitations and tightness or mild pain in the chest – Epigastric discomfort – Numbness, tingling or paresthesia of the fingers, toes and lips – Muscular twitching, carpopedal spasms and tetany . – Headache, faintness, fatigue and mental confusion – Loss of consciousness
  17. 17. Treatment: • Maintain patent airway • Mental rapport in calming the patient • If the patient overbreathe, he should be allowed to breath into a paper bag or ambu mask at a rate of 10 times per min • After symptoms abate the patient should be allowed to breathe room air at a rate of 12-14 times per min
  18. 18. Prevention- • Follow stress reduction protocol • Administration of sedation
  19. 19. Allergic reactions • Results from an immunologic response by a patient who has become sensitized to the drug through a prior exposure • Can be either cellular(delayed) or humoral(immediate) • Cellular reaction is mediated by cellular reaction mediated by lymphocytes derived from the thymus gland which react directly with an antigen • Humoral type mediated through serum antibodies that are produced by lymphocytes derived from the bone marrow • Humoral allergic responses may vary from a mild skin reaction to anaphylaxis • More common in adults than in children
  20. 20. Recognition: • Skin reactions • Drug fever • Organ cytotoxicity • Serum sickness • Anaphylaxis • Most common is the skin eruptions which can be – Urticarial – Bullous – Erythematous – Maculopapular – Nodular – Edematous – petechial
  21. 21. • Can be accompanied by pruritis and edema • Respiratory problems – Allergic rhinitis – Edema – Bronchospasm – Wheezing – Dyspnea – Cyanosis – Asphyxia • Circulatory problems – Pallor and mild hypotension – Vascular collapse – Irreversible shock
  22. 22. Treatment: • Treated as soon as possible • Cutaneous symptoms – Antihistamines orally – Severe cases- IM or IV route preferred using diphenhydramine HCl 50mg or other suitable anti histamines followed by oral tablets – If it progresses and extensive edema is present then epinephrine 1:1000 should be injected subcutaneously or IM. And may be repeated in 10-15 mins if necessary • respiratory symptoms- – Bronchospasm and wheezing – 0.3-0.5mg 1:1000 epinephrine should be given SC/IM and repeated in 10-15 mins
  23. 23. – Patent airway should be maintained – Oxygen administration – Respiration should be supported when necessary – Antihistaminic drug should be given after that followed by corticosteroids-hydrocortisone 100mg or methylprednisolone 40mg or dexamethasone 8mg IM/IV can be given – Steroids require more than one hour to act, so it should always be given after the other drugs • Circulatory symptoms – Moderate reaction treated same as the respiratory symptoms – If the reaction is truly an anaphylactic shock, then • Place the patient in a supine position • Maintain ABC • Administer epinephrine 1:1000 0.5mg IM • Monitor vital signs • Titrate epinephrine 0.2 to 0.3 mg IV slowly if IV route is available • Administer IV fluid rapidly • Administer antihistamines IV/IM • Administer steroid IM/IV • Recognize and treat any concomitant problem, i.e. vomiting, convulsion, cardiac arrhythmias
  24. 24. Prevention: • Take accurate history • Patients should be observed for a valid period of time after a drug has been administered
  25. 25. Airway obstruction by foreign body • Caused by swelling of the neck owing to infection or trauma, tumors growing in the airway, unconsciousness causing the tongue to fall back and block the airway or foreign bodies at any level along the air passages • When a foreign body disappears from the oral cavity and there are signs of bronchial irritation, it must be presumed to have passed into the respiratory passage until proved otherwise-McCarthy 1972 • Symptoms may be mild or patients may cough, gag choke, or wheeze • If only mild symptoms are present then a radiograph of the chest should be taken to confirm the location of the body, then should be referred for its removal bronchoscopy or thoracotomy if bronchoscopy is unsuccessful
  26. 26. • With complete obstruction the patient may gasp for breath with great effort, show suprasternal and intercostal retraction and be unable to speak • The chest may rise and fall, but this should not be considered as air exchange until it can be felt with the back of the hand- thompson 1975
  27. 27. Treatment: • Try leaning the patient over the chair and pound on his back • Small children may be held upside down by their legs and sharp blows rendered to their backs • If unsuccessful the patient should be laid supine on the floor and with head to the side and the mouth pen, the middle and index finger should be placed deep into the pharynx and swept laterally in an effort to dislodge the foreign body • If laryngoscope and Magill forceps are available, then it can also be used for the removal • If the obstruction is incomplete, then mouth to mouth or ambu bag can be used to move enough air round to be life saving
  28. 28. • Another procedure to be considered before attempting surgical intervention is Heimlich procedure- Heimlich 1974 • This maneuver increases the pressure in the trachea and larynx and dislodges the obstruction
  29. 29. • If all else fails then surgical intervention is necessary • Cricothyroidotomy or coniotomy is the procedure of choice • Cricothyroid space is located easily by observation and no major nerves or vessels pass through that region • If airway maintenance is required for more than 48 hrs, then a tracheotomy should be considered
  30. 30. Prevention: • Utilize care when dealing with the instruments inside the oral cavity • A gauze screen protecting the pharynx should be placed whenever the patient is undergoing procedures under GA or sedation
  31. 31. Asthma-Bronchospasm • Generalized contraction of the smooth muscles of the bronchi and bronchioles • Seen commonly in patients with asthma • With an asthmatic attack there is bronchospasm, mucosal edema and intraluminal secretions all of which contribute to airflow obstruction • Present as very mild with few symptoms or as status asthmaticus, a life threatening episode initially unresponsive to therapy with hydration and bronchodilators wheezing is a prominent sign • Patient may be diphoretic, anxious and shows labored breathing with use of accessory muscles and intercostal retraction
  32. 32. • Subjectively, patient shows – Shortness of breath – Wheezing – Chest tightness – Chest congestion • This is followed by symptoms of fatigue, panic fear and irritability(kinsman et al, 1973) • Leads to hypoxemia which can result in cyanosis and confusion
  33. 33. Treatment • Consist primarily of bronchodilators, supplemented with oxygen and hydration • Patient should be in an sitting position • Oxygen administration 20-30%is useful but is seldom used • First try the medication the patient is having and using • If that is unavailable, then epinephrine 0.3-0.5mg SC should be administered and may be repeated in 15mins. • If this fails, then aminophylline should be used • A loading dose of 5-6mg/kg in 5% D/W can be given intravenously over 15-20mins • Following loading dose, 1mg/kg/hr can be started. Stopped at the sign of irritation
  34. 34. • If asthma still persists, then the patient should be carried into an emergency room Prevention; • Proper medical history should be taken and anything which is allergic to the patient should be removed • Elective surgery should be delayed if the patient complains of any respiratory diseases • Mild sedation should be used • Narcotics should be avoided • Aspirin should be avoided as it can worsen the condition in several patients
  35. 35. Hypertensive emergency • When a resting adult has an arterial pressure above 150/90 mm Hg, hypertension may be considered to be present • They have possibility of ↑ed bleeding problems related with therapy with antihypertensive medication and increased sensitivity to sedatives and epinephrine • Acute HT episode should be considered when an extremely high elevation of diastolic BP, 120mmHg or greater is seen along with – Headaches – Dizziness – Nausea – Vomiting – Signs of visual impairment – Other neurologic changes
  36. 36. • Retinal changes – Hemorrhages – Exudates – Papilledema • If not treated promptly it may lead to other complications such as angina pectoris or stroke
  37. 37. Treatment: • Try to reduce the blood pressure to a range of 100-110mmHg • Patient should be allowed to rest in a semi resting position • Oxygen administration • Small amount of diazepam slowly titrated IV route, to reduce the blood pressure • Small dose of chlorpromazine can also be used to lower the blood pressure • if oxygen and small amount of diazepam, is not able to reduce the blood pressure, then the patient should be carried out to the OT
  38. 38. Prevention: • An accurate medical history should be taken • A preoperative BP should be take to assess the BP and to measure it as a baseline • Should always consider the possibility of orthostatic hypotension when under antihypertensive medication • A maximum of 0.2mg epinephrine per appointment is permissible( NY heart association, 1955) • Avoid intravascular injection • Sedation should be encouraged as this helps the patients to relax and avoid any HT crisis
  39. 39. Hypotensive emergency • It is the ↓ in BP and should be diagnosed from shock • The pulse may be weak • Bradycardia • A systolic pressure less than 80mmHg is considered as hypotensive • If shock is also associated then the patient will also show agitation, restlessness, confusion, nausea, stupor and coma(staples 1973)
  40. 40. Treatment: • Initially supportive therapy • Patient should be placed in trendelenburg’s position and oxygen administered • Vital signs should be monitored upon closely • IV line should be administered for possible fluids and drugs • If pulse <60, atropine 0.4-0.6mg IV • In patients using antihypertensive medications, norepinephrine or phenylephrine should be used • Phenylephrine 2-5mg SC/IM preferred or 0.2mg IV infusion can also be used
  41. 41. • If MI or cerebrovascular accident is suspected, then least potent vasopressor, mephenteramine can be used IV/IM. A dosage of 15mg for systolic BP in between 60-80. if <60, 30mg can be used Prevention: • Take proper medical history
  42. 42. Ischemic heart disease • Results from an inadequate perfusion of a portion of the myocardium • Etiology include atherosclerosis of the coronary arteries • Resultant ischemia may lead to arrhythmias, conduction defects or cardiac failure • Majority of the patients present with angina pectoris, MI or sudden death • Angina pectoris is a paroxysmal discomfort often described as heaviness, tightness, choking or squeezing(Herman 1971) • The pain is characteristically retrosternal but may radiate to the arms and shoulders, particularly on the left side
  43. 43. • The pain is relieved by rest or nitroglycerine • Pain of MI is similar to angina pectoris, but is more severe and prolonged, not alleviated by rest or nitroglycerine and other symptoms like weakness, pallor, nausea, sweating and restlessness are more often seen
  44. 44. Treatment: • The procedure should be stopped and the patient should be put in a semisitting position and oxygen administered • A tablet of nitroglycerine, preferably the patients own medication is placed sublingually. If the patient has no nitroglycerine, a 0.03mg nitroglycerine tablet should be placed under the tongue. • If effective, relief should be seen in 45 seconds to 2 mins. If pain persists, sublingual nitroglycerine can be placed twice at 5min interval. • If the pain is severe an ampule of amyl nitrate broken under the patients nose can be tried
  45. 45. • If effective it should provide relief within 30 secs. • Since these drugs are vasodilators, headache, flushing dizziness and even syncope can be seen • If all fails, then the patient should be suspected to have MI and the patient should be send to the emergency room • If heart failure develops, corrective measures should be instituted • If pain is severe, meperidine 25mg can be given IM/IV titer • If hypotension is present, mephenteramine 15-30mg IM can be given • CPR should be instituted if respiratory depression exists
  46. 46. Prevention: • Take proper medical history • Risk factors – Hypertension – Cigarette smoking – hypercholesterolemia – sex – Age – Obesity – DM – Positive family history – Aggressive, deadline conscious personality
  47. 47. • If the patient is giving history of stable angina, then short appointments and sedation should be considered to minimize stress • In case of unstable angina, elective surgery should be carried out with the physicians consultation • With a recent history of angina, the treatment should be postponed for atleast 6 months
  48. 48. Congestive heart failure • It is the inability of the heart to pump sufficient blood to the body tissues to meet ordinary body demands(parmley 1977) • problems in the dental office includes, signs and symptoms of heart failure in patients with underlying heart disease or a change from chronic to acute heart failure during surgical treatment • With left heart failure – Dyspnea – Orthopnea – Paroxysmal nocturnal dyspnea – Chronic cough – bronchospasm
  49. 49. • With right heart failure – ↑ed jugular venous distension – positive hepatojugular reflex – Hepatomegaly – Peripheral edema • General heart failure – Fatigue – Weight loss – Tachycardia – A third heart sound – Cardiac enlargement
  50. 50. • The symptoms of general heart failure is accentuated by pulmonary edema, with the occurrence of bronchospasm and cyanosis • There is often frothy pink sputum production and chest is filled with rales which can be heard on auscultation
  51. 51. Treatment: • Based on the underlying cause, reducing the cardiac load and controlling excessive fluid retention • Digitalis is useful in these cases due to its inotropic effect • When acute pulmonary edema is present, patient should be placed in sitting or semisitting position to reduce the venous return to the heart • Oxygen 100% administered possibly under positive pressure • Morphine can be given IM/IV to decrease vascular resistance and in turn decrease the venous return • Dosage depends upon the severity and route of administration of the drug
  52. 52. • Tourniquets or blood pressure cuffs can be placed on the upper and lower limbs, being applied to constrict the veins to restrict the blood supply and does not interfere with the arterial supply • Rapidly acting furosamides and digitalis are also utilized • If bronchospasm present, then aminophylline can be used
  53. 53. Prevention: • Proper medical history • If a patient has an episode of acute ischemic episode in the office, patient should be observed carefully for development of heart failure • Patient should be placed in sitting or semisitting position
  54. 54. Cardiopulmonary arrest • It is the sudden cessation of the circulation and ventilation • Causes include – GA – LA – Sedation – Asphyxia – MI – Allergic reactions to medications • Lack of ventilation can be identified by the lack of thoracic or abdominal movements, the absence of air movements from the mouth or the nose.
  55. 55. • Absence of circulation is identified by the absence of femoral or carotid pulse, confirmed by the manifestations of inadequate cerebral perfusion, i.e. dilated pupils, unresponsiveness, comatose state, and by inadequate peripheral perfusion by the ashen gray color.
  56. 56. Treatment: • CPR • BLS consists of the ABC of the CPR – A- maintaining the airway – B-breathing – C-circulation • Started ASAP, because irreversible heart damage can cause within 4-6 mins • Most important immediate action is the opening 0of the airway • If spontaneous breathing doesn’t resume, then artificial ventilation should be started using anesthetic machine r ambu bag or mouth to mouth respiration or mouth to nose ventilation
  57. 57. • Oropharygeal airway and endotracheal intubation- only should be used when the patient is unconscious • Once the patency of the airway is established, then ventilation should be continued at the rate of once every 5 secs in adults and once every 3 secs in infants and small children • Supplemental oxygen should be used as soon as possible • if circulation is absent, then artificial circulation by external cardiac massage should be initiated • With only one rescuer, a ratio of 15:2 should be maintained, i.e. 15 chest compressions for 2 quick lung inflations
  58. 58. • Pupils that constrict in response to light indicate adequate blood flow to the brain • After 2 mins of CPR, sodium bicarbonate, 1mEq/kg should be given IV as a bolus or as a continuous infusion over a ten min period to combat metabolic acidosis • Initial dose should be repeated after 10 mins, thereafter half the dose at every ten mins • It should be used along with epinephrine which increases myocardial contractility, elevates perfusion pressure, helps restore electrical activity and enhances defibrillation in ventricular fibrillation • Dosage-0.5mg IV every 5 mins
  59. 59. • Atropine-sinus bradycardia with a pulse less than 60beats/min • Dosage-0.5mg IV repeated at 5 min interval until the pulse exceeds 60bpm • Defibrillation should be carried pout in case of ventricular fibrillation • Complications of CPR – Fracture of the ribs and sternum or separation and fracture of the costochondral junctions – Fat and bone marrow emboli – Hemothorax – Pneumothorax – Hemopericardium – Lacerations of the liver, spleen and the stomach
  60. 60. Prevention: • Good history • Recognizing high risk patients • Adequate monitoring during the procedure
  61. 61. Diabetic emergencies • Two complications – Insulin shock(hypoglycemia) – Ketoacidosis (hyperglycemia) • Both conditions are more likely to occur in patients who have onset juvenile diabetes • Hypoglycemia is the more common occurrence in dental office • Occurs when there is inadequate carbohydrate intake in relation to the insulin or oral hypoglycemic medication • Ketoacidosis usually develops over a period of several days • Symptoms are usually caused by excessive sympathetic activity
  62. 62. • They usually occurs when the blood glucose falls below 40mg% • Patient may show pallor, sweating and tremor and may have apprehension palpitations weakness and hunger • with inadequate cerebral glucose, irritability, mental confusion, depression, headache and other neurologic symptoms such as speech and visual disturbances will occur • If no treatment is instituted, then convulsion, coma, or death may ensue • They usually have a slightly elevated BP and pulse
  63. 63. • In diabetic ketoacidosis, patient gives a history of thirst, polyuria, and polydipsia and may have nausea, vomiting, abdominal pain, confusion, and ultimately coma • Rapid breathing • Odor of acetone may appear in the breath • Patient appears ill and dehydrated due to polyuria • Rapid pulse, ↓ed BP and skin turgor, dry mouth and enophthalmus
  64. 64. Treatment: • Hypoglycemia- – Administer 10-20gm of glucose or its equivalent orally – unconscious- giving glucose 20-50ml of 50% glucose should be administered IV route – If failed to give in IV route, then 1mg of glucagon can be given IM, SC. Its peak action occurs within 10-15 mins • Ketoacidosis – Best if carried out in a hospital because it requires giving administering insulin, monitoring fluids and electrolytes, vital signs, blood gases and other parameters – Patient should be placed in a supine position and should be transported into the hospital
  65. 65. Adrenal insufficiency • Occurs with patients who are taking steroids or has been taking steroids • Causes the suppression of the anterior pituitary • Duration of the treatment is more important than the amount of drug taken • When exogenous steroids are given for less than ten days, the pituitary adrenal axis recovers within a mater of hours. • When it is given for more than a year, then it will take as much as 9 months to recover • ACTH suppression is less likely to occur after two months of the cessation of the treatment
  66. 66. • Consultation with the physician is necessary before commencing the treatment in steroid treatment taking or taken patients • It is characterized by – Anxiousness – Severe nausea and Vomiting – Abdominal pain – Cool and clammy skin – Lethargy and hypotension – Shock
  67. 67. Treatment: • Administration of steroids to ↑ the circulating hormone level • If the patient is responsive, then 100 to 200mg of a soluble hydrocortisone preparation added to 1000ml of 5% D/S allowed to run over 4 hrs is often advocated • 100mg cortisone acetate is also given to prolong the action • Profound shock- 100mg hydrocortisone IV – If no response then the dosage can be ↑ed to 400-500mg • Vasopressors can also be used to combat hypotension
  68. 68. Prevention: • Good medical history • Physicians opinion if the patient has taken medication for – Arthritis – Asthma – Regional enteritis – Ulcerative colitis – Some types of hepatitis – Pemphigus – Severe dermatoses – For prevention of graft rejection in kidney transplant patients – Conjugation with other medications for the treatment of malignancies
  69. 69. • Recommendation for steroid taking patients – Mild stress- double the daily dose – Moderate stress- oral hydrocortisone 100mg or prednisolone 20mg daily – Severe stress- hydrocortisone 200mg or prednisolone 40mg
  70. 70. Epileptic convulsion • Chances of seizure occurring during the treatment • Status epilepticus, two or more seizures occurring without intervening consciousness is the most possibility having a mortality rate of about 10-20% • Convulsions may also occur due to infection, fever, neurologic problems, metabolic imbalances and toxic reactions to drugs including LA • A grand mal epileptic seizure is usually characterized by generalized seizure usually lasting less than 5 mins, preceded by aura that may consist of sensor, motor or psychic sensations
  71. 71. • There is loss of consciousness, urinary or fecal incontinence and one usually sees injury from falling or tongue and cheek biting • Respirations might become jerky • The postictal stage is usually characterized by drowsiness, headaches and confusion
  72. 72. Treatment: • Airway maintenance, patient protection and patient protection and termination of convulsions • Patent airway should be maintained and any oral appliances or dental prosthesis should be removed immediately tight restricting clothing should be removed • Oxygen administration to protect against hypoxia • If vomiting occurs, then the head should be tilted to the side and the oral cavity should be suctioned off of any vomit or saliva • By judiciously restraining the patient, injury during the seizure can be prevented • Tongue biting should be prevented using tongue blades or towels
  73. 73. • If convulsion doesn’t stop for several minutes, drug should be administered • Diazepam 5-10mgIV(5mg/min) • In children, 0.25 to 0.50mg/kg • Initial dose might be repeated after 5 to 10 mins • Maximum dose 30mg/hr • Can be given IM if IV route is difficult • Succinyl choline IV/IM can also be used
  74. 74. Prevention: • Adequate history • Procedures delayed if the patient is not under good control • If a patient has seizure in the office he should be taken home with assistance because of postictal depression
  75. 75. Cerebrovascular accident • Unlikely event in a dental office • Result from thrombosis, embolism or hemorrhage all of which result in focal brain damage • Mainly afflicts elderly population with atherosclerosis being the most common reason • Other reasons include – Vascular malformations – Inflammatory diseases of the arteries – Hematologic disorders – Hypertension – Hypotension – Drugs such as oral contraceptives and anticoagulants
  76. 76. • Hallmark of CVA is the sudden change in neurologic function with the specific symptoms depending on the area and extent of brain damage • Weakness, hemiplegia, hemianesthesia and speech and visual problems may occur. Severe headache is frequent if its due to hemorrhage
  77. 77. Treatment: • Mainly supportive • Patient should be kept comfortable • Patent airway should be maintained and oxygen administered If respiratory difficulty develops • The head should be kept elevated to reduce the risk of hemorrhage • Patient should be immediately transported to the hospital for further treatment
  78. 78. Prevention: • Look for the susceptible patients which includes – Elderly patients – Hypertensive patients – Patients with evidence of arteriosclerosis, which includes angina pectoris, MI, or peripheral vascular disease
  79. 79. conclusion • Taking an adequate medical history can prevent many mishaps in the dental office. • If in doubt about the status of the patient, the treatment should always be postponed until a physicians concern is obtained. • A clinician should always be alert ad should be able to identify the condition and instate proper treatment at the right time. At the first sign of the patient being stable, he should be shifted to higher centre for proper medical treatment without delay • All the emergency medicines should be at reach and always the medication should be kept ready and staff should know where all the medications are
  81. 81. REFERENCES 1. ORAL AND MAXILLOFACIAL SURGERY. DANIEL M LASKIN 2. CLINICAL MEDICINE-MURRAY LANGMORE 3. MEDICAL EMERGENCIES IN DENTAL OFFICE-STANLEY F MALAMED 4. Haas A Management of Medical Emergencies in the DentalOffice: Conditions in Each Country, the Extent of Treatment by the Dentist: Anesth Prog 53:20–24 2006 5. Fast TB, Martin MD, Ellis TM. Emergency preparedness:a survey of dental practitioners. J Am Dent Assoc. 1986;112:499–501 6. New Zealand Code of Practice Medical Emergencies in Dental Practice 7. The ADA Practical Guide to Patients with Medical Conditions
  82. 82. 8. Basic management of medical emergencies Recognizing a patient’s distress-JADA 2010;141(5 suppl):20S-24S 9. INTERNET RESOURCES