This document provides information on managing various dental emergencies. It discusses the basic principles of managing medical emergencies, including establishing airway, breathing, and circulation. It also covers the management of specific conditions like syncope, asthma, diabetes, hypertension, angina, myocardial infarction and more. The document emphasizes the importance of assessing the patient's condition, stabilizing vital signs, determining the appropriate treatment, and when necessary, consulting physicians or activating emergency services.

1. Emergencies in dental clinic
How to deal

2. An emergency is
 medical condition that requires immediate attention and successful
management
 These are the life-threatening situations of which every dental
practitioner must be aware so
 that unwanted morbidity can be avoided.
 Emergencies can be prevented to a certain extent by recording a
detailed medical history, doing a complete physical examination, and
thorough patient monitoring

3. Basic Principles Of Management Of Medical
Emergencies
Basic life support (BLS) measures and cardiopulmonary
resuscitation (CPR).
This is done by following the basic principles:
 Position (P), Airway (A), Breathing (B), Circulation (C), and
Definitive therapy (D)

4. The basic positions to manage an emergency are
supine position,
Trendelenburg position,
 semi-erect position

6. Maintaining a patent and functioning airway is
the first and important procedure in managing
an emergency
This is achieved usually by the head tilt-chin lift maneuver.

8.  The next priority is to check for the presence of adequate breathing is
assessed by the
 look-feel and listen-to technique
 If spontaneous breathing is not evident then rescue breathing should
be initiated immediately
 either by the mouth-to-mouth technique or the bag-valve-mask
technique.

9. Next step
circulation is assessed
 by palpating the carotid pulse at the region of the sternocleidomastoid
muscle, radial artery

10. In case of absence of pulse
 CPR is initiated immediately.
 When airway, breathing, and circulation are maintained,
 definitive treatment is initiated. Definitive therapy involves the
 administration of an ideal drug to relieve symptoms.

11. Basic life support (BLS)

12. Syncope
general term referring to a sudden, transient loss of
consciousness that usually occurs secondary to a period of
cerebral ischemia
Types
1) psychogenic factors
 2) non psychogenic
NB:Normal adult RR is 12-20 breaths/min and child RR is 20-30 breaths/min.

13. The psychogenic factors for syncope are
Fright, Anxiety, Emotional stress, undesirable
news, Sight of blood/surgical/dental
instruments

14. Non -Psychogenic factors are Erect sitting or
standing, posture, starvation or a missed meal,
Exhaustion, Poor physical condition , crowded
environment.

15. presyncope
 Before going into syncope
 patient will have certain signs and symptoms such as Warm feeling in
face and neck, pale or ashen coloration, sweating, feels cold, abdominal
discomfort, lightheadedness or dizziness, mydriasis (Pupillary
dilatation.), Yawning, Increased heart rate, a slight decrease in blood
pressure

16. During syncope
the patient loses consciousness. Generalized muscle
relaxation will happen, Bradycardia (Weak thready
pulse.,Seizure (Twitching of hands, legs, and face.),

17. the post syncopal
Once the patient recovers during the post syncopal period
there will be a Variable period of mental confusion, Heart
rate increases (Strong rate and rhythm.), Blood pressure back
to normal levels.

18. Pathophysiology of syncope
 When the body experiences Stress
 the Catecholamines( include dopamine, epinephrine (adrenaline), and
norepinephrine (noradrenaline). get released into the blood, this is the body’s
response to stress it is known as the “ fight or flight “ response. Increased
catecholamines will lead to changes in tissue blood perfusion and decrease peripheral
vascular resistance and increase the blood flow to many tissues especially the skeletal
muscles for the muscular action to take place. If the expected muscular action takes place
the muscle will pump the blood back to the heart so the blood pressure remains at a base
level so the signs of syncope don’t occur. when the muscular activity doesn’t take place,
the patient remains static in the dental chair. The blood starts pooling in the periphery
which leads to decreased cardiac output followed by decreased in circulating blood
volume and decreased arterial BP this ultimately leads to decreased cerebral blood flow

19.  What triggers catecholamine release?
 Splanchnic nerve stimulation is the physiological stimulus
for catecholamine secretion. Stimulation of the splanchnic
nerves results in the release of ACh from nerve endings in the
adrenal medulla.

20. Management
 Check ABC Assess & open airway (head tilt &chin lift); assess airway patency& breathing;
assess circulation (palpation of carotid pulse).
 Lie flate , elevate legs, untighten clothes once awake offer glucose in tea or drink
 Lf not
 Move on to definitive management administer O2 Monitor vital signs( not mostly
needed). Administer aromatic ammonia vapor which I a respiratory stimulant that helps to
increase breathing and muscular movement. Administer atropine 0.5mg IM if bradycardia
persists. Once the patient recovers dental treatment should be postponed
Atropine inhibits the effect of acetylcholine by complexing the acetylcholine receptor on the other
side of the cleft, subsequently inhibiting the binding of acetylcholine. If atropine does not allow
acetylcholine to bind to the acetylcholine receptor, then the effects of acetylcholine are inhibited.

21. Mechanism Of Action
Atropine competitively blocks the effects of
acetylcholine, including excess acetylcholine
Atropine increases the heart rate and improves
the atrioventricular conduction by blocking the
parasympathetic influences on the heart.

25. Postural Hypotension
The predisposing factors of postural hypotension are Drugs
such as anti-hypersensitive, opioids and histamine blockers,
Prolonged period of recumbency or convalescence,
Inadequate postural reflex, Late-stage pregnancy, Advanced
age,

26. Pathophysiology of postural hypotension
When the patient is in the supine position the blood
pressure is equally distributed throughout the body
When the body alters the position to Semi supine the
BP decreases by 2mm Hg for every 1 inch when the
patient moves into supine to upright the Influence
of gravity in CVS is increased.

27. Management
The patient must be placed in a supine position with feet
elevated.
 ABC Assessed following which oxygen is administered at
the rate of 8-15ml per minute. patients vital signs are
monitored and chair reposition should be done slowly

28. Foreign Body Airway Obstruction
due to accidental slippage, aspiration of foreign objects, or
laryngeal spasm.
Usage of Rubber dam, Gauze, Suction, Magill’s intubation
forceps, Ligature using dental floss Can help in preventing
the intraoral objects from slipping inside the airway

29. Management
If the object is visible with the help of the assistant place the
patient in a supine position or Trendelenburg position, the
object is retrieved using Magill intubation forceps, in the
absence of an assistant instruct the patient to bend over the
arm of the chair with their head down and Encourage the
patient to cough to expectorate the object

31.  If it fails Kneel or stands behind the victim and wraps arms around
the victim’s waist and makes a fist with one hand, Place the thumb side
of the fist against the victim’s abdomen

34. Establishing an emergency airway –
Non invasive procedures
Invasive procedures

35. Asthma
chronic inflammatory disorder of the airways it is
characterized by recurrent and often irreversible airflow
limitations due to underlying inflammatory processes

36. Confirm that they have taken their most recent
scheduled dose of medication,
 The patient’s metered-dose inhaler bronchodilator
should be on hand, Procedure should be done late
morning/afternoon,

37. can be triggered by many things, including dust, traffic
fumes, pollen, stress and even the weather.
 An asthma attack occurs as aresult of being exposed to
an asthma trigger, which causes the small airways (the
bronchi and bronchioles) become narrower, or
constricted, making breathing more difficult

39. Management
Sit the casualty upright, leaning on a chair, if necessary
(the dental chair is ideal). Help them to use their
inhaler. (It is much easier to administer the drug
successfully if they can do this themselves). Two “puffs”
should be administered initially,
 (the dose of salbutamol is 100mcgper puff) but this
can be repeated every few minute if the attack does not
ease

40. The early use of a spacer device

41.  inhaler should be administered via the spacer one puff at a
time, inhaled separately using Tidal breathing.
 according to response, give another puff every 60 seconds up
to a maximum of ten puffs

42.  Oxygen must also be administered
 If the episode continues, epinephrine is administered IM 0.01mg/kg
up to 0.5 mg. When the episode subsides discharge the patient and
postpone the dental treatment if it continues activate EMS

43. ‫اكتر‬ ‫تلخيص‬
If the pat cannot breath , cyanosis , confused , decrease level of consciousness >>>>>

45. Management of hyperventilating patients
 • Assess airway breathing and circulation; identify any disability
 • Reassure patient
 • Encourage patient to decrease respiratory rate slowly
 • If there is obvious sympathetic overactivity, as shown particularly
 by tachycardia or arrhythmias, a cardiologist’s opinion should be
 obtained, as treatment with a beta-blocker may be necessary
 • Defer dental treatment until medical assessment has taken place

46. Diabetes Mellitus
Diabetes is the most common endocrine disorder. It is
marked by high levels of blood glucose resulting from
defects in insulin production, insulin action, or both

47. Hyperglycaemia
 Clinical symptoms include thirst, increased urine output and
dehydration, and also, there may be hypotension, progressive
reduction in level of consciousness, coma or cessation of urinary
output in severe cases.
 Management
 Primary assessment and resuscitation , is to secure the airway,
breathing and circulation. Then transport to a hospital facility.

48. Hypoglycaemia
Clinical symptoms of hypoglycaemia include sweating,
hunger, tremor, agitation, with progressive drowsiness,
confusion and coma. Assume any diabetic with
impaired consciousness has hypoglycaemia until
proven otherwise
Low blood sugar is called hypoglycemia. A blood
sugar level below 70 mg/dL (3.9 mmol/L) is low and
can harm you.

49. If the patient is conscious and cooperative, offer the
patient 15–20 g of quick-acting carbohydrate; for
example, , one bottle (60 ml) Glucojuice or 150–200
ml pure fruit juice.
Chocolate is no longer recommended for the
treatment of hypoglycaemia because its fat content
slows the absorption of quick-acting carbohydrate

50.  In unconscious patients, 50ml of dextrose is given in 50%
concentration
 or 1mg glucagon intravenously, or give 1ml glucagon intramuscular
almost any body site. Paediatric dose of glucagon 0.5 ml or ,<8 yrars
old or less than 25 kg
 Following the treatment, the signs and symptoms of hypoglycemia
should resolve in 10 to 15 minutes, once stabilized, the patient is
transported to a hospital for definitive care and observation. Postpone
the dental procedure. When the condition doesn’t cease activate EMS

52. Epileptic seizures

53. Epileptic seizures
 All patients with epilepsy should have a personalised care
plan,
 Thiopental 50 mg 2.5-5% or valium iv
 Buccolam contains midazolam hydrochloride 5 mg/1 ml in
pre-filled oral syringes of 2.5 mg, 5 mg, 7.5 mg and 10 mg
 Stop any procedures dismiss the patient

54. 5/11/2023
54
Hypertension
 Defined as blood pressure Greater Than 140/90

55.  To recapitulate: Questions for the dentist to consider when deciding on
 dental care are:
 What is the actual BP number?
 Is therapy elective or emergent?
 Will the procedure be long or invasive?
 What is the health of the patient?
 Is there any advice from the patient’s physician

58.  ASA Class I. A normal healthy patient
 ASA Class II. A patient with mild systemic disease
 ASA Class III. A patient with severe systemic disease
 ASA Class IV. A moribund patient who is not expected to survive without
 the operation

59.  <160/100 No modification in ttt plan
 Considering pat status, age, oral health

60.  >160/100* Repeat measurement
If lowered or within written guidance from a physician, proceed
If confirmed, no elective dental treatment and the patient should seek consultation with a physician
Emergency Dental Care:
Repeat measurement
If lowered or within written guidance from a physician, proceed
If confirmed systolic pressure 160–180 mmHg and/or diastolic pressure 100–109 mmHg where dental symptoms
and pain contribute to hypertension, initiate emergency care with blood pressure monitoring every 10 to 15
minutes during procedure; consider anxiety reduction techniques
If confirmed systolic pressure >180 mmHg and/or diastolic pressure >109 mmHg, seek consultation with a
physician before proceeding

61.  One cartridge of anesthetic containing 1:50,000 epinephrine;
Two cartridges of anesthetic containing 1:100,000
epinephrine; or
Four cartridges of anesthetic containing 1:200,000
epinephrine
 Not recommended to uncontrolled patients

62. 5/11/2023
62
Hypertension
Management
 Control BP before elective treatment
 Reasonable control of severe hypertension before emergency treatment
 Medical consult before treatment for uncontrolled hypertension

63. Angina pectoris
 is an acute coronary syndrome associated with transient ischemia to the
myocardium.
 Hypoxia results from diseases and conditions which lead to atherosclerosis and
obstruction of coronary arteries by fatty deposits that limits and/or impairs
coronary blood flow.
 Precipitating factors that increase cardiac oxygen demand in the presence of
decreased perfusion of the myocardium include physical exertion, emotional stress,
cold, recent meal. Unstable angina pectoris may occur spontaneously at rest

64.  Prevention by decrease pain and anexcity
 Anaesethia with VC according to pat physical status
• Symotoms
• Chest pain that feels like pressure or indigestion.
• Pain that radiates to your left shoulder or down your left arm.
• Shortness of breath.
• Dizziness.
• Nausea.
• Exhaustion.

65.  occurs chiefly as
 i. stable angina
 a type of chest pain that happens when your heart muscle needs more
oxygen than usual but it's not getting it at that moment because of heart
disease
 ii. unstable angina.
 Chest pain with no effort exerted

66.  should not implement the Procedures without prior consultation with the
appropriate primary or specialist care provider(s) if the patient/history or present
condition appears suggestive of unstable angina and/or if the patient/client is
taking an antiplatelet agent (other than low-dose ASA) — as often happens with
cardiac stenting — or an anticoagulant2 (e.g., warfarin3 or a direct oral
anticoagulant), which increases risk of bleeding.

67.  may postpone the Procedures pending medical advice if the patient
 a. is experiencing symptoms suggestive of stable angina and is not receiving
routine medical care
 b. has not complied with pre-medication, such as nitrates, as directed by the
prescribing physician
 c. has recently changed significant medications, under medical advice or
 otherwise

68.  Administer nitroglycerine – if patient’s prescription not available – administer
0.3/0.4 mg sublingually.
 If pain persists five minutes after nitroglycerine dose,
 repeat administration.
 If still no response,
 repeat nitroglycerine and administer oxygen 2/4 L/min
 If angina does not subside – concerned that myocardial infarction is developing.
Transfer to emergency room

69. Myocardial Infarction
 Myocardial infarction is caused by abrupt anoxia to a portion of the heart resulting
in myocardial tissue necrosis.
 Heart Attack (Myocardial Infarction) A heart attack (medically known as a
myocardial infarction) is a deadly medical emergency where your heart muscle
begins to die because it isn't getting enough blood flow. This is usually
caused by a blockage in the arteries that supply blood to your heart
 Anoxia results from conditions that lead to the formation of atherosclerotic
plaques. In later stages, atherosclerotic plaques may become disrupted and
contribute to thrombus formation. Atherosclerotic plaques and thrombi impair
blood flow to large and medium-sized arteries of the heart. History of
cardiovascular diseases, diabetes mellitus, and cerebrovascular disease increases
the overall risk of perioperative MI

71. Strock ‫دماغية‬ ‫سكته‬
 Facial weakness
 Arm weakness
 Problems in speech
 Management
 • Assess, clear airway and check breathing
 • Check pulse and capillary refill
 • Reassure the patient
 • Give high-flow oxygen 15l/min
 • Call ambulance
 • Defer dental treatment

72. Adrenal crisis
 The adrenal glands (AGs), part of the body’s endocrine system, are two small
organs located on top of the kidney.
 Two parts : cortex and medulla
 Cortisol is secreted from the cortex
 Cortisol is involved in
1. the mechanisms of adaptation of the organism to stress maintaining homeostasis;
2. - it has anti-inflammatory and immunosuppressive effect,
3. it is responsible for mobilizing fatty acids from adipose tissue,
4. it maintains vascular reactivity, it promotes the liver’s protein synthesis via
neoglycogenesis,
5. it increases gycemia
6. it inhibits bone formation and delays healing

73.  . AGs insufficiency can be primary
 known as Addison’s disease (AD),
or secondary, resulting from long-term glucocorticoids
 treatments or more infrequently from pituitary disorders . AC is common mainly in
the primary type of the diseas

74. Addison’s disease
 The most frequent etiology of AD is the autoimmune destruction of the Ags
 Other causes can be involved in primary adrenal insufficiency such as infections
(sepsis, tuberculosis, etc.), adrenal hemorrhage, sarcoidosis, lymphoma etc
 Signs and symptoms of AD vary considerably, from generalized weakness and
malaise to weight loss with/without anorexia, nausea and vomiting, diarrhea or
constipation, abdominal pain, hypotension, electrolyte imbalance (from metabolic
acidosis to hyponatremia and hyperkalemia), vitiligo and other autoimmune
lesions, reduced pubic and/or axillary hair,
 normal ranges of cortisol are:
• 6 to 8 a.m.: 10 to 20 micrograms per deciliter (mcg/dL)
• Around 4 p.m.: 3 to 10 mcg/dL
 Treatment of AD includes lifetime glucocorticoid (hydrocortisone)

75. Management of patients with AD in dental
clinic
 For Miller et al 2001., general anesthesia, infections, stress, and pain augment the
risk of AC in predisposed patients
 ‫العدوي‬ ‫او‬ ‫الخوف‬ ‫او‬ ‫الوجع‬ ‫نتيجه‬ ‫مشكلة‬ ‫تسبب‬ ‫ممكن‬ ‫االسنان‬ ‫بالتالي‬ ‫و‬

76. Important
As for the patients’ ability to tolerate dental
care, dentists are required to apply a stress-
free protocol in pre-, per- and post treatment
and to make sure of long-acting anesthesia
and postoperative pain control

77. In a classification adopted by the American Dental
Association (Patton and Glick, 2016), Miller et al.2001
classified the risk, from dental procedures, for
patients with adrenal insufficiency into 3 categories,
negligible, mild, and moderate/major risks

79. If it happened on chair
If the patient develops adrenal crisis, call 999 immediately,
if the patient’s emergency hydrocortisone injection kit is available,
administer intramuscular (IM) hydrocortisone. The recommended
dose, which should be stated on the patient’s adrenal crisis letter,
depends on the patient’s age:
Adults: 100 mg
Children six years of age or older: 50–100 mg (use clinical
judgement depending on the age and size of the child)
Children one to five years of age: 50 mg
Infants up to one year of age: 25 mg.

80. ‫تلخيص‬
 Dental management of the patient with Addisonian crises
- interrupt dental procedure,
- place the patient in dorsal decubitus and contact with the corresponding medical
emergency service.
- Until medical help arrives, the patient should be administered oxygen (5-10 liters/min).
- If the patient is unconscious, he should be placed in dorsal decubitus with the legs raised,
- If an adrenal cause is suspected, 100 mg of hydrocortisone should be administered
intravenously or intramuscularly, within 30 seconds if possible, and two hours later,
another 100 mg of hydrocortisone dissolved in saline for intravenous or intramuscular
injection should be provided

81. Doses of drugs equivalent
to 20 mg of cortisone
 Hydrocortisone 20 mg
 Prednisone 5 mg
 Dexamethasone 0.75 mg

82. Anaphylactic shock

83. Anaphlaxis
 Pathophysiology
 In IgE-mediated anaphylaxis, the first contact of the allergen with the
host results in the production of specific IgE antibodies by plasma
cells – a process called sensitization.
 Subsequent exposure to the allergen causes cross linking of the IgE
antibodies and aggregation of their receptors
 This results in the
 release of preformed mediators (such as histamine, tryptase
carboxypeptidase A, proteoglycans, chymase and TNF-a) and newly
synthesized mediators (such as leukotrienes, prostaglandins, TNF-a,
platelet-activating factor)

84. genetic variation has a role in the severity of the
response to the allergen in sensitized individuals.

85. Anaphylactoid reactions (non-allergic
anaphylaxis)
do not require previous exposure to the allergen.
There are a number of mechanisms implicated in the
process and these vary depending on the agent.
Mechanisms include direct activation of mast cells
and basophils to cause histamine release, as well as
activation of the kallikrein-kinin system and
complement and clotting cascades.

87. Most common ch.ch
Urtecaria and angioedema
Shortness of breath
Hypotension systole less than 90
For a diagnosis of anaphylaxis, there should be an acute
onset (minutes to hours) of two or more of: skin-mucosal
involvement; respiratory compromise; hypotension and
associated symptoms; and persistent gastrointestinal
symptoms

90. ‫نفرق‬ ‫ازاي‬ ‫مهمه‬
‫بين‬ vasovagal aatack and
vasovagal attack in anaphylasis
Vasovagal reactions feature hypotension, nausea, vomiting,
diaphoresis and bradycardia
in anaphylaxis it is usually tachycardic, although it can also be
bradycardic, and therefore this may not be a reliable
distinguishing factor
Other features in the favour of a vasovagal reaction include the
rapidity of onset, maintenance of a central pulse and prompt
response to supine positioning

92. Pirafen amp 5mg/1ml
allergyl tab 4mg
Solu cortef vial
100/2ml
Sultan 50 mg cap

93. example of how to place an unconscious
patient into the lateral recovery position – always ensure that the chin is
in an elevated position to maintain airway patency