Medical emergencies in dental practices

©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, “When you prepare for an emergency,
the emergency ceases to exist.”

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CLASSIFICATION OF LIFETHREATENING EMERGENCIES
• UNCONSCIOUSNESS
– VasodepressorSyncope
– Postural Hypertension
– Acute Adrenal Insufficiency

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• RESPIRATORY DISTRESS
– Foreign Body Airway Obstruction
– Hyperventilation
– Asthma
– Myocardial Infarction or Angina

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• ALTERED CONSCIOUSNESS
– Diabetes Mellitus: Hyperglycemia and Hypoglycemia
– Cerebro vascular Accident
• SEIZURES

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• DRUG RELATED EMERGENCIES
– Drug OverdoseReactions
– Allergy
• CHEST PAIN
– Angina Pectoris
– Acute Myocardial Infarction

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ANXIETY
Symptomsofanxietydisorderinclude:
• Feelingsofpanic,fear, anduneasiness.
• Problemssleeping.
• Coldor sweatyhandsand/orfeet.
• Shortnessofbreath.
• Heartpalpitations.
• Aninabilitytobestillandcalm.
• Drymouth.
• Numbnessor tinglinginthehandsor feet.

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SYNCOPE
 Vasovagal syncope
 Simple faint is the most common medical emergencyseen in dental
practice.
 Loss of consciousness duetoinadequate cerebral perfusion
 Mediated by autonomic nerves.

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SYNCOPE
• Fainting can beprecipitated by
Psychogenicfactors
• Fright
• Anxiety
• Emotional stress
• Receipt of unwelcome news
• Pain especially sudden &unexpected
• Sight of blood/ surgical/ dental instruments
• (e.g.local anesthetic syringe)

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Non psychogenicfactors
• Erect sitting orstanding posture
• Hunger from dieting or a missed meal
• Exhaustion
• Poor physical condition
• Hot, humid, crowded environment
• Male gender
• Agebetween 16 and 35 years

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• Warm feeling in face and neck.
• Pale orashen coloration.
• Sweating.
• Feels cold.
• Abdominal discomfort, Nausea and/or vomiting;
• Lightheaded ordizziness.

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• Mydriasis (Pupillary dilatation.)
• Yawning.
• Increased heartrate initially later bradycardia
• Steady orslight decrease in blood pressure.
• Seizures
• Loss ofconsciousness

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Stress
Catecholamines release
peripheral vascular resistance & ↑blood flow to peripheral muscles
↓venous return
↓circulatory 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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 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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TRENDLENBURGPOSITION

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SYNCOPE
• 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
• 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).
• Thereis increase in frequency ordepth of respiration, orboth.
• Commonest emergency in dental office always occurs as a result of
extremeanxiety.

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Anxiety
Increased rateand depth of respiration
↑exchangeof O2 & CO2 by lungs
↑ blowing off of CO2 and paCO2 decreases
Hypocapnia
↑in blood pH
Respiratory alkalosis

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Recognizeproblem (rapid , deep,uncontrolled breathing)
P –Position patient comfortably, usually upright
A → B→C–Basic life support as needed
D –Definitive care:

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 Prevention:
Through prompt recognition and management of anxiety.
Stress reduction protocol is the primary means of preventing
hyperventilation.

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• Removedental materials from patient’s mouth
• Calm patient
• Correctrespiratoryalkalosis – instructed to breathe 7% CO2 & 93% O2
orto rebreathe the exhaled air.
• Initial drug management –Benzodiazepines
• Dental caremay continue if both doctor and patient agree
• Discharge patient

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STROKE
Stroke:
• Stroke may beeither hemorrhagic orembolic.
• Signs and symptoms varyaccording to the site of brain damage.
• Loss of consciousness andweakness of limbs on one side of the body.

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FAST

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• Oneside of the face may becomeweak.
• As stroke causes an upper motor neuron lesion, the forehead muscles of
facial expression will be unaffected.
• Speechmay becomeslurred.

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Initialmanagement ofa stroke includes the following:
 Theairway should be maintained and anambulance called.
 High flow oxygen (10litres perminute) should begiven.
 The patient should be carefully monitored for any further
deterioration.

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HYPOGLYCEMIA
 Theproper casehistory- diabetic control.
 Varying blood glucose levels- hypoglycaemia.
 Treat them during morning appointment.
 Medication and food prior to appointment.

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HYPOGLYCEMIA
• Thesigns and symptoms of hypoglycemia include:
 Trembling
 Hunger
 Headache
 Sweating
 Slurring of speech

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HYPOGLYCEMIA
 ‘Pins and needles’ in lips and tongue
 Aggression and/or confusion
 Seizures
 Unconsciousness.

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Management of Hypoglycemia

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Management of Hypoglycemia

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ANAPHYLAXIS

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ANAPHYLAXIS
• „Thesigns and symptoms of anaphylaxis include:
 „Itchy rash/erythema.
 Facial flushing orpallor.
 „Upper airway (laryngeal) oedema and bronchospasm leading to
stridor, wheezingand, possibly, hoarseness.

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Management of Anaphylaxis
• Diphenhydramine Hydrochloride (Avil)
• 1:1000 Adrenaline
• Hydrocortisone 100mg

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ANAPHYLAXIS
Initial treatment for anaphylaxis includes thefollowing:
• „The ABC approach should be employed while the diagnosis is being
made.
• Airway and breathing should be managed by administering 10
litres/min of oxygen.
• Blood pressure should berestored by lying the patient flat.

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• In life-threatening anaphylaxis (hoarseness, stridor, cyanosis, dyspnoea,
drowsiness, confusion or coma), adrenaline should be administered in the
following way.
• „Administer 0.5 ml of 1 in 1000 adrenaline (epinephrine) IM and repeat
at 5minute intervals if no improvement.
• Theoptimum site for injection is the anterolateral mid-third of the thigh.

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ADRENAL CRISIS
Adrenalcrisis:
• It may result from adrenocortical hypofunction leading to hypotension,
shock anddeath.
• It maybe precipitated by stressinduced by trauma, surgery orinfection.

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Thesigns and symptoms of adrenal crisis include:
• „The patient loses consciousness.
• „The patient has a rapid, weak orimpalpable pulse.
• „The blood pressure falls rapidly.
• It is important in the history to ascertain whether the patient has recently
used oris currently using corticosteroids.

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ADRENAL CRISIS
• Acute adrenal insufficiency can often be prevented by the administration
of a steroid boost prior to treatment.
• Ruleof 2
• Invasive procedure such as oral surgical procedures or very
apprehensive patients, may requirecover.
• 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:
• „Lay the patient flat andraise his/her legs.
• „Ensure a clearairway andadminister oxygen.
• „Call anambulance.

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ANGINA / MYOCARDIAL INFARCTION
• Moderate to crushing central chest pain, radiating to left arm, neck or
mandible.
• Stop treatment, place one glyceryl trinitrate tablet 0.6 mg under tongue
orspray under tongue.
• Repeat dose in 5 minutes.
• If noimprovement after 15 minutes,
treat asacute myocardial infarction.

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Signs &Symptoms ofMyocardial Infarction

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MYOCARDIAL INFARCTION
• Chest pain similar to angina but unrelieved by up to 3 glyceryl trinitrate
tablets over10minutes.
• Call for medical help.
• Monitor vital signs.
• 100% oxygen.
• Dissolved aspirin tablet and one glyceryl trinitrate dose stat and one
repeat in 5minutes after checkof BP.

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SEIZURES
• Abnormalbrainactivity
ClinicalFeatures:
 Aura
 Tremors
 Confused
 Sleepy
 Trancelikestate
 Frothing

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ASTHAMA
• It is defined as “a chronic inflammatory disorder that is
characterized by reversible obstruction of the
airways.”

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Status asthmaticus:
• More severeclinicalform
• Experiencewheezing,dyspnea,hypoxia
• Refractoryto2–3dosesof β-adrenergicagents
• Ifnotmanagedadequately,patientmay dieduetorespiratory
distress

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Prevention:
Medical history regarding
• Lung diseases
• Allergies to drugs, food, medication, latex
• Usage of drugs, medications, natural remidies

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Clinical manifestations:
• Feeling of chest congestion
• Cough, with orwithout sputum production
• Wheezing
• Dyspnea
• Patient wants to sit orstand up
• Use of accessory muscles of respiration
• Increased anxiety and apprehension
• Tachypnea (>20 - >40 in severecases)
• Rise in B.P, Increase in heartrate (>120 bpm in severecases)

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Onlyin respiratory distress
• Diaphoresis
• Agitation
• Somnolence
• Confusion
• Cyanosis
• Supraclavicular and intercostal retraction
• Nasal flaring

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Recognizeproblem (respiratory distress, wheezing)
Discontinue dental treatment
Activate office emergencyteam
P –Position, usually upright with armsthrown forward
A → B→ C–Assess and perform basic life support as needed
D –Definitive 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

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