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Medical emergencies in the dental operatory
1.
2. MEDICAL EMERGENCIES
IN THE DENTAL OFFICE:
HOW TO AVOID A BAD DAY
Dr.Aditi Singh
P.G. 1st year
Dept. Of Preventive & Pediatric Dentistry
SDCH,Rishikesh
5. CASE # 1
A 62 y/o anxious female needs extraction of four erupted
teeth. Her past medical history is positive for Type II
diabetes and a history of seizures many years ago.You
inject her with mandibular block. After five minutes you are
summoned to the operatory by your assistant. The patient
is unconscious. What could be happening and what do
you do?
16. PREVENTION
Know who‟s at risk!
Medical history
History
forms
Verbal history
Physical exam (vital signs)
Blood
Pulse
pressure
17. PATIENT EVALUATION
Past medical history
Serious
illnesses
Current medical care
Hospitalizations and operations
Medications
Allergies
Paint a picture
24. AIRWAY OBSTRUCTION-DEFINITION7
Mechanical blockage of air exchange
Tongue
Foreign
body
7.Kenichi Obinata, Takafumi Satoh, Alam Mohammad Towfik and
Motoyasu Nakamura:An investigation of accidental ingestion during
;
dental procedures;Journal of Oral Science,53(4)495-500 2011
27. TREATMENT6
6. Umesan et al :Prevention and management of accidental foreign body ingestion and aspiration
in orthodontic practice, Therapeutics and Clinical Risk Management 2012:8;245–252
32. MANAGEMENT OF HYPOCHLORITE ACCIDENT5
5. M. Hülsmann & W. Hahn:Complications during root canal irrigation–literature review and case
reports,International Endodontic Journal,33;186–193, 2000
41. HYPERVENTILATION-TREATMENT1
Stop procedure
Clear all objects from
mouth
Verbally calm the patient
Rebreathe CO2
Self-limiting problem
Diazepam 5 mg IV or
midazolam 2 mg IM/IV
No O2
Paper
bag
Face mask
Hands
1.European Resuscitation Council Guidelines for Resuscitation 2010
50. DIAGNOSIS 1,4 …
ANGINA
Diaphoresis
Shortness of breath
Nausea
Unsettling to patient
MYOCARDIAL INFARCTION
Angina that is prolonged or
not responsive to
nitroglycerin
Pallor
Shortness of breath
Unconsciousness
Weak pulse
54. SYNCOPE-DEFINITION 2,3
Transient and reversible loss of blood flow to brain
causing decreased sensorium or fainting
Vasovagal syncope is the most common cause of
loss of consciousness in the dental office
Generally caused by anxiety
55. SYNCOPE-PATHOPHYSIOLOGY2,3
Stress catecholamine release blood
redistribution to skeletal muscle
Lack of muscle activity lack of cardiac return
fall in blood pressure activation of pressure
receptors to maintain blood pressure
Receptors fatigue precipitous fall in blood
pressure loss of consciousness
61. SYNCOPE-DIAGNOSIS3
Early Diagnosis
Pale
Diaphoretic
Room “feels warm”
Nausea
Pulse rapid
BP nearly normal
Late Diagnosis
Loss of consciousness
Possible seizure activity
BP extremely low
Pulse extremely slow and
weak
63. SYNCOPE-TREATMENT3
Cool towel to forehead
Monitor vital signs
Ammonia vaporole
At increased risk for a
second faint
Call it a day
Consider
premedication/sedation
67. POSTURAL HYPOTENSION- PRECIPITATING FACTORS2,3
Rapid vertical change in body position in persons
at risk
Dehydration
Blood loss
Allergic reactions
MI
Not induced by stress
68. POSTURAL HYPOTENSION-DIAGNOSIS2,3
Patient feels light-headed upon rapid standing
Loss of consciousness
Vital signs differ from vasovagal syncope:
Blood pressure low
Pulse normal or rapid
69. POSTURAL HYPOTENSION-TREATMENT2,3
Identical to treatment of vasovagal syncope
Elevate slowly when recovered
At no greater risk of repeat loss of consciousness
than before episode
70. POSTURAL HYPOTENSION-PREVENTION
Do not allow patients at risk to rapidly stand from
the dental chair
Elevate patients slowly and in stages
Be prepared to physically support the patient if they
pass out
72. SEIZURE-RISK FACTORS
Patients with a history of seizures
Frequency
Last
seizure?
Precipitating factors (stress?)
Medications
Last time serum drug levels were checked
Changes in medications since last check
75. SEIZURE-TREATMENT1
Stop dental treatment, all objects out of mouth
Remove dangerous items from around patient
Gently restrain and protect patient during ictal
phase
NO tongue blades
1.European Resuscitation Council Guidelines for Resuscitation 2010
76. SEIZURE-TREATMENT1
Supportive therapy during post-ictal phase
Maintain airway
Oxygen
Monitor vital signs
Call emergency dept., especially if seizure
continues or repeats
Possible valium 5-10 mg IV or midazolam 2-4 mg
IV/IM if seizure continues or repeats
1.European Resuscitation Council Guidelines for Resuscitation 2010
81. ALLERGIC REACTIONS-RISK FACTORS2,3
Patients with known prior allergic reactions
Careful
history
Specifics of previous reaction
Timing of the event
Treatment required
Atopic patients
Patients may demonstrate cross reactivity to
medications of a similar chemical structure
85. ALLERGIC REACTIONS-TREATMENT1
Delayed onset skin reaction
Stop dental
treatment/medications
Assess respiration
Consider observation if
localized
If more generalized,
diphenhydramine (Benadryl)
25-50 mg TID x 2 days
1.European Resuscitation Council Guidelines for
Resuscitation 2010
86. ALLERGIC REACTIONS-TREATMENT1
Immediate skin reaction
Stop
dental treatment
Assess respiration
Diphenhydramine 25-50 mg IM/IV
Diphenhydramine 25-50 mg po TID x 2 days
1.European Resuscitation Council Guidelines for Resuscitation 2010
87. ALLERGIC REACTIONS-TREATMENT1
Respiratory or
cardiovascular
compromise
Stop
treatment
emergency dept.
Oxygen
Basic life support as
indicated
Intubation/ cricothyrotomy
1.European Resuscitation Council Guidelines for
Resuscitation 2010
Epinephrine
0.3-0.5 mg
SC/IM/IV
Bronchodilator inhaler if
wheezing present
Diphenhydramine 25-50 mg
IM/IV
Hydrocortisone 100 mg IM/IV
88. ALLERGIC REACTIONS-PREVENTION
Careful medical history
Don‟t use the drug
Avoid prescribing medications in the same class as
those to which known allergy exists
Prophylactic antihistamines?
100. WHAT SHOULD YOU HAVE IN YOUR EMERGENCY KIT?3
Oxygen
Epinephrine
Chlorpheniramine maleate
Sugar/cake frosting
Ammonia inhalants
Atropine
Diazepam
Hydrocortisone
Inhaler-Albuterol
Nitrospray/nitroglyceride
tablets
Aspirin
Paper bag
3.Stanley F Malamed Medical Emergencies in the dental office, ed 6 Mosby 2007
101. CONCLUSIONS
A medical emergency in the dental office can be a
frightening experience for the patient as well as the
doctor and staff
With proper preparation, prevention, diagnosis and
treatment the risk of a disastrous outcome can be
greatly reduced
102. CONCLUSIONS
Be prepared (yourself, staff, office)
Obtain a thorough knowledge and understanding of your
patient‟s medical conditions to determine medical risk
Alter normal routine dental treatment to minimize risk
Be alert to early signs and symptoms of an impending
medical emergency, and institute early and rapid treatment
104. REFERENCES ..
1.European Resuscitation Council Guidelines for Resuscitation
2010
2.Jeffrey D.Bennet,Morton B.Rosenberg Medical Emergencies for
Dentistry,ed 1,2002 Saunders
3.Stanley F Malamed Medical Emergencies in the Dental
Office,ed 6 Mosby 2007
4.American Heart Association CPR ECC Guidelines 2010
5. M. Hülsmann & W. Hahn:Complications during root canal
irrigation–literature review and case reports,International
Endodontic Journal,33;186–193, 2000
6. Umesan et al :Prevention and management of accidental
foreign body ingestion and aspiration in orthodontic practice,
Therapeutics and Clinical Risk Management 2012:8;245–252
105.
7.Kenichi Obinata, Takafumi Satoh, Alam Mohammad Towfik and Motoyasu
Nakamura:An investigation of accidental ingestion during dental
procedures;Journal of Oral Science,53(4)495-500; 2011
8.http://www.nlm.nih.gov/medlineplus/ency/article/003399.htm
9. Rosen‟s Emergency medicine : Concepts and Clinical practice 7ed
10.Ahmad IA. Rubber dam usage for endodontic treatment: a review. Int
Endod J. 2009 Nov;42(11):963-72.
11.Anabtawi MF, Gilbert GH, Bauer MR, Reams G, Makhija SK, Benjamin PL,
Williams OD. JADA Continuing Education: Rubber dam use during root canal
treatment: Findings from The Dental Practice-Based Research Network.
JADA. 2013 144(2): 179-186.
12. Mohammad Hoseini,Seyed Morteza Saadat Mostafavi,Navid
Rezaei,Ehsan Javadzadeh Boluri: Orthodontic Wire Ingestion during
Treatment: Reporting a Case and Review the Management of Foreign Body
Ingestion or Aspiration:Case Rep Dent. 2013