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Medical emergencies in dental practice
- 1. MEDICALEMERGENCIESIN DENTAL PRACTISE & BASICLIFESUPPORT DR.USHA HATHGAIN ,MDS ORALAND MAXILLOFACIAL SURGERY
- 2. “When you preparefor emergencies, they cease to exist!” - Goldberger What is an emergency?
- 3. APPROACH TO AMEDICAL EMERGENCY Prevention Preparation Management
- 4. Prevention “Never treat astranger” Medical history Physical examination Psychological examination OBSERVATION DETERMINATION OF MEDICAL RISK
- 5. • ASA ClassI. 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 patient with an incapacitating systemic disease that is constant threat to life • ASA Class V-A moribund patient not expected to survive 24 hrs with or without operation • ASA E- Emergency operation of any variety ASA PHYSICAL STATUS CLASSIFICATION RISK ASSESSMENT
- 6. Staff training Training in the recognitionand management of specific emergency situations Basic life support Office preparation Posting emergency assistance numbers Emergency drugs and equipment Emergency “fire drills” Preparation
- 8. The emergency drugsbox - time for action? BJD VOLUME 187, NO. 2, JULY 24 1999
- 9. ALERT Did you know??? A person who receives BLS has 20%increase in survival rate than one who does not…so just act..
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- 13. “C” CIRCULATION /COMPRESSION COMPRESSION RATE= 100-120/MIN COMPRESSION DEPTH = 1.5-2 INCHES(5CM AT LEAST) COMPRESSION : VENTILATION = 30:2
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- 15. MEANS OF SECURINGAIRWAY AIRWAY
- 16. Airway Obstruction ◘ Re-establishmentof airway: Non-invasive procedures Forceful coughing Back blows Heimlich maneuverChest thrust Finger sweeps Invasive procedures
- 17. “B” BREATHING • LOOK •LISTEN • FEEL TIME FOR ACTION METHODS OF RESCUE BREATHS • MOUTH TO MOUTH OR NOSE • MOUTH TO BARRIER DEVICE •VENTILATION WITH BAG AND MASK •VENTILATION WITH ADVANCED AIRWAY
- 18. DEFIBRILLATION AUTOMATED EXTERNAL DEFIBRILLATOR(AED) ATTACH PADS TO CASUALTY’S BARE CHEST ANALYSING RHYTHM DO NOT TOUCH VICTIM SHOCK INDICATED SHOCK DELIVERED FOLLOW AED INSTRUCTIONS NO SHOCK ADVISED FOLLOW AED INSTRUCTIONS 30 2
- 19. IF VICTIM STARTSTO BREATHE NORMALLY PLACE IN RECOVERY POSITION
- 21. COMMONLY ENCOUNTERED EMERGENCIES &MANAGMENT
- 22. EMERGENCIES ENCOUNTERED CANBE !!!!! UNCONSIOUSNESS • Syncope • Hypotension • Hypoglycemia •SEIZURES •ADRENAL CRISIS CARDIOVASCULAR EMERGENCIES • Angina pectoris • Myocardial infarction RESPIRATORY EMERGENCIES • Airway obstruction • Asthma DRUG-RELATED EMERGENCIES • Overdose reactions • Allergies/ANAPHYLAXIS
- 23. EMERGENCIES ANGINA ADRENAL CRISIS SYNCOPE ASTHAMA HYPERVENTILA TION HYPOGLYCEMIA ACUTE MYOCARDIAL INFRACTION CARDIACARREST EPILEPSY ANAPHYLAXSIS ACUTE AIRWAY OBSTRUCTION HYPERGLYCEMIA HYPOTENSION
- 25. SYNCOPE • It isdefined as sudden, transient loss of consciousness that is usually secondary to period of transient ischemia. • Predisposing factors: STRESS IMPAIRED PHYSICAL CONDITION HYPOGLYCEMIA Stress=Tachycardia=Carotidbody & sinus stimulation Vagal stimulation= Bradycardia, Vasodilation=Decreased cerebral blood flow Reflexive response to reestablish cerebral blood flow=syncope How to identify ? Sings /symptoms H.R. UNCONSCIOUS CONVULSION PUPIL DILATION SWEATING NAUSEA PALLOR ANXIETY B.P. Webster-Merriam’s Medical Dictionary. 12th ed. Baltimore:Williams;2011.“syncope”;p.348 PATHOPHYSIOLOGY
- 26. MANAGEMENT OF SYNCOPE STOPALL DENTAL PROCEDURE IMMEDIATELY ASSESS CONSCIOUSNESS ACTIVATE OFFICE EMERGENCY TEAM PUT PATIENT IN SUPINE POSITION WITH FEET ELEVATED ASSESS AND OPEN AIRWAY AND ASSESS CIRCULATION* ACTIVATE EMS IF RECOVERY IS NOT IMMEDIATE ADMINISTER OXYGEN 10L FLOW/min MONITOR VITAL SIGNS •PROVIDE DEFINITE MANAGEMENT OF UNCONSCIOUSNESS: LOOSENING OF BINDING CLOTHES, START 5D RINGERS LACTATE IV, EPINEHRINE 0.3-0.5mg IM/IV AROMATIC AMMONIA, ATROPINE 0.4mg IV (REPEAT UPTO 1.2mg), IF BRADYCARDIA PERSISTS MAINTAIN COMPOSURE POSTSYNCOPAL RECOVERY , ARRANGE ESCORT HOME DELAYED RECOVERY, ACTIVATE EMS P CAB
- 27. POSTURAL/ORTHOSTATIC HYPOTENSION Drugs Prolonged recumbency / convalescence Latestage pregnancy Varicosities Addison’s Disease Severe exhaustion Shy-Drager Syndrome PREDISPOSING FACTORS PATHOPHYSIOLOGY Pt attains upright position SBP falls =<60mm of Hg due to ANS response failure Cerebral blood flow<critical level Loss of consciousness Supination=revival Criteria for postural hypotension. 1.Symptomology develops on standing 2.Increase in standing pulse atleast 30 beats per minute 3.Decrease in standing systolic BP atleast 25 mm of Hg 4.Decrease in standing diastolic BP atleast 10 mm of Hg Second leading cause of unconsciousness How to identify ? Sings /symptoms •DIZZINESS •PALLOR •BLURRED VISION •NAUSEA • BP
- 28. MANAGEMENT OF POSTURALHYPOTENSION Recognize problem Activate office emergency team Position the patient (supine with feet slightly elevated) A B C &Definitive management of unconsciousness (O2,) Episode continuesEpisode terminates Summon medical assistantProvide subsequent management Slowly reposition chair Discharge pts
- 29. Acute Adrenal Insufficiency Acondition first recognized by Addison in 1844. PREDISPOSING FACTORS •Addison’s disease . •Pts on long term steroid therapy(RULE OF TWOS) •Stress CLINICAL PRESENTATION •Shock, •Anorexia, •Nausea, •Vomiting, •Abdominal Pain, •Weakness, •Fatigue, •Lethargy, •Fever, •Confusion,or Coma PREVENTION Acute adrenal insufficiency is best managed by its preventionwhich is based on 1. Medical history questionnaire. 2. Dialogue history.
- 30. MANAGEMENT OF ACUTEADRENAL INSUFFICIENCY Terminate dental therapy Position patient comfortably if asymptomatic Supine with feet elevated, if symptomatic Monitor vital signs Summon medical assistance Administer oxygen • Administer glucocorticoid 100 mg of hydrocortisone sodium succinate (IV or IM) and repeat every 6 – 8 hours •Dexamethasone 4mg IV 6-8 HRS • Additional management: provide Basic Life Support as needed • Provide oxygen as needed • Maintain iv line
- 31. SEIZURES Diagnostic clues •Sudden onsetof immobility and blank stare • Show blinking of eyes • Short duration • Rapid recovery •It is a paroxysmal disorder of cerebral function characterized by an attack, involving changes in the state of consciousness, motor activity or sensory phenomena. • Usually sudden in onset and of brief duration.
- 32. Terminate the dentalprocedure Position the patient comfortably Seizure stops seizure continues > 5 min Reassure patient summon medical assistance Allow patient to recover basic life support as indicated and discharge MANAGEMENT
- 33. HYPOGLYCEMIA Blood glucose levelsbelow 3.0mmol per litre.
- 34. MANAGEMENT CONCIOUS PATIENT UNCONCIOUSPATIENT RECOGNISE HYPOGLYCEMIA…… TERMINATE DENTAL PROCEDURE POSITION PATIENT ( SUPINE WITH LEGS ELEVATED) BASIC LIFE SUPPORT ,ASCESS A-B-C ADMINISTER ORAL CARBOHYDRATE EPISODE TERMINATE EPISODE CONTINUES PERMIT PATIENT RECOVERY SUMMON MEDICAL ASSIATANCE DISCHARGE PATIENT ADMINISTER PARENTRAL CARBOHYDRATE ( GLUCAGON 1MG IM /2-3 MIN OR 50% DEXTROS IV) MONITER VITALS DISCHARGE SUMMON MEDICAL ASSIATANCE( NO RESPONSE TO BLS) DEFINITIVE T/T GLUCAGON 1MG IM 50% DEXTROS IV, TRANSMUCOSAL SUGAR 0.5MG EPINEPHRINE (1:1000) IM/SC,REPEAT IN 15 MIN AS NEEDED ALLOW PT. TO RECOVER MONITOR VITALS DISCHARGE
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- 37. ANGINA PECTORIS “A conditionmarked by severe pain in the chest, often also spreading to the shoulders, arms, and neck, owing to an indequate blood supply to the heart.” • Types: - Stable - Variant - Unstable Clinical characteristics – Poorly localized pain – Brief duration(2-10 minutes) – Moderate intensity pain described as squeezing, oppressive, burning or heavy • Pain localized with one finger • Lasts less than 30 seconds or longer than 30 minutes • Pain described as sticking, jabbing,throbbing or constantly severe Stress reduction Reassurance Psychosedation Excluded if: PREVENTION
- 39. MYOCARDIALINFARCTION “A clinical syndromecaused by deficient coronary arterial blood supply resulting in ischaemia to a region of the myocardium and causing cellular death and necrosis.” – Atherosclerosis and coronary artery disease – Coronary thrombosis, occlusion and spasm – Males – 5th and 6th decades of life – Undue stress Predisposing Factors: •STRESS REDUCTION PROTOCOL •OXYGEN SUPPLEMENT •PSYCHOSEDATION PREVENTION
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- 41. CARDIAC ARREST Abrupt cessationof cardiac pump function that results in death , which may be averted if prompt intervention is instituted. PREDISPOSING FACTORS •90% Coronary artery disease •Obesity- Male in 5th and 6th decade •stress PRECAUTIONS •Stress reduction protocol •Oxygen supplement •Sedation HOW TO IDENTIFY ? •Sudden and abrupt loss of conciousne •Absence of respiration •Loss of central and pheripheral pulse •No heart sound CLINICAL MANIFESTATIONS Sever retrosternal pain radiating to lt. arm Restlessness, distress Pale and moist skin Dizziness,palpitation, prespiration Nausea, vomitting Irrigular heart rate
- 42. MANAGEMENT BLS ACLS TERMINATE DENTAL PROCEDURE MONITORVITALS DEFINITIVE TREATMENT •NITROGLYCERINE •ANTIPLATELET THERAPY- ASPIRIN 325MG •MANAGE PAIN- PARENTRAL OPOIDS, N2O+ O2 DIAGNOSE- DIFFERENTIATE ANGINAL PAIN WITH NON-ANGINAL PAIN P POSITION PATIENT COMFORTABLY C-A-B TRANSFER TO HOSPITAL SUMMON MEDICAL ASSISTANCE
- 44. AIRWAY OBSTRUCTION/FOREIGN BODY ASPIRATION ◘May occur due to: o Pathology on the airway o Dental instruments o Tongue PREVENTION Rubber dam Oral packing Chair position Dental assistant Magill’s intubation forceps
- 45. MANAGEMENT ◘ Re-establishment ofairway: Non-invasive procedures Forceful coughing Back blows Heimlich maneuverChest thrust Finger sweeps Invasive procedures
- 46. FOREIGN BODY ASPIRATION STIOPDENTAL PROCEDURE ASK PT. TO COUGH OUT OBJECT OBJECT EXPELLED OUT BACK BLOWS RE-EXAMINE PT. EVALUATE FOR RESIDUAL OBJECT/ SUCCESS NJURY TO TRACHEOBRONCHEAL TREE UNSUCCESSFUL ( CHEST X-RAY,ENDOSCOPY) CONCIOUS UNCONCIOUS SUSPECT COMPLETE OBSTRUCTION HEIMLICH MANOEUVRE HEIMLICH MANOEUVRE SUCCESSFUL UNSUCCESSFUL CONCIOUS UNCONCIOUS SUCCESSFUL UNSUCCESSFUL CHECK VITALS VITALS,BLS EMERGENCYAIRWAY MAINTAIN BREATHING AIRWAY M/M VITALS,BLS 02 /AIRWAY RECOVERY NO RECOVERY SHIFT TO HOSPITAL CALL EMERGENCY MEDICAL SUCCESSFUL UNSUCCESSFUL
- 47. ASTHMA A clinical stateof hyper reactivity of the tracheobronchial tree, characterized by recurrent paroxysms of dyspnea and wheezing. Can be: • Extrinsic Asthma • Intrinsic Asthma • Status Asthmaticus Feeling of chest tightness Dyspnea Tachypnea Cough Use of Accessory/Respiratory Muscles Agitations Signs and symptoms
- 49. HYPERVENTILATION Excessive rate anddepth of respiration leading to abnormal loss of carbon dioxide from the blood primarily predisposed to stress and anxiety. Rapid short strained breaths Cold sweats Palpitations Dizziness Chest muscle fatigue • Characterized by:
- 50. MANAGEMENT • Terminate procedure •Rebreathing bag (exhaled air) • Drug management – 10 to15 mg diazepam or 3 to 5 mg Midazolam IV •Resume procedure • Calm patient •Check vitals • Correct respiratory alkalosis (breathe in gaseous mixture of 7% CO2 and 93% O2) • Position patient (upright)
- 52. OVERDOSE REACTIONS In adental practice, commonest overdosage>>LA • Confusion, talkativeness, blurred speech • Muscular twitching, facial tremor •Headache, tinnitus •Drowsiness, disorientation • Elevated BP, HR, RR • If uncontrolled, seizures CLINICAL MANIFEATATIONS -Stop administration of LA -Place the patient in supine position -Monitor vital signs -Administer oxygen -anticonvulsants(Administer diazepam 5-10mg slowly.) - Perform BLS as needed - Allow recovery to occur - In case of continuation of symptoms, summon EMS MANAGEMENT
- 53. Anaphylaxis Acutely life threateningcondition. Reactions develop rapidly 5-30 minutes. Four major clinical syndromes are: 1. Skin reactions 2. Smooth muscle spasm 3. Respiratory distress 4. Cardiovascular collapse BRONCHOSPASM CARDIAC ARREST
- 54. MANAGEMENT Identify anaphylactic reaction •Position patient in upright position • Assess ABC • Definitive management: • Epinephrine (1:1000),0.3 mg IM or SC every 5 mins • Oxygen by nasal hood or face mask at rate of 5 to 6 L/min - Im histamine blocker ( chlorpheniramine maleate 10 mg ) - IV access and administration of additional histamine blockers and corticosteroids( hydrocortisone 20 mg) Summon Medical Assistance CPR ,If cardiac arrest Transfer to hospital
- 55. CONCLUSION As thesaying goes, “PREVENTION IS BETTER THAN CURE”. ALWAYS BE PREPARED. Prompt recognition and efficient management of medical emergencies by a well-prepared dental team that can increase the likelihood of a safe & satisfactory outcome. Basic life support training – A MUST
Editor's Notes
- #3 ◘ A serious and unexpected situation requiring an immediate action. It is an unforeseen combination of circumstances or the resulting state that calls for an immediate action.
- #5 Never treat a stranger” Physical Evaluation Medical history questionnaire Physical examination (vital signs, visual inspection, functional tests, auscultation of heart and lungs) Dialogue history (recognition of anxiety) Psychological examination Medical history questionnaire Anxiety questionnaire Observation Increased BP & Heart rate Trembling Excessive sweating Dilated pupils Physical status classification system (1962, American Society of Anesthesiologists) ASA I : A patient without systemic disease, a normal healthy patient ASA II : A patient with mild systemic disease ASA III : A patient with severe systemic disease that limits activity but is not incapacitating ASA IV : A patient with incapacitating systemic disease that is a constant threat to life. ASA V : A moribund patient not expected to survive 24 hrs with or with out surgery. ASA VI : Clinically dead patient being maintained for harvesting organs. ASA E : Emergency operation of any variety; E precedes the number, indicating the patients physical status( ASA E-III) Medical consultation Stress reduction protocol Premedication Appointment scheduling Minimized waiting time Psycosedation during therapy Adequate pain control during therapy Duration of dental treatment Postoperative control of pain and anxiety
- #6 The concept of ‘‘how healthy is the patient,’’ otherwise termed ‘‘risk assessment,’’ is key in determining the likelihood of complications. The higher the ASA class, the more at-risk the patient is both from a surgical and anesthetic perspective. • 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 patient with an incapacitating systemic disease that is constant threat to life • ASA Class V-A moribund patient not expected to survive 24 hrs with or without operation • ASA E- Emergency operation of any variety
- #7 Staff training should include: Basic life support training for all members of dental office staff Training in the recognition and management of specific emergency situations Emergency “fire drills” A fire drill is a method of practicing how a building would be evacuated in the event of a fire or other emergencies. In most cases, the building's existing fire alarm system is activated and the building is evacuated by means of the nearest available exit as if an emergency had actually occurred. Office preparation should include: Posting emergency assistance numbers Stocking emergency drugs and equipment
- #8 Suction equipment Blood pressure monitor Ambu bag and airways Oxygen delivery equipment and tubing Syringe for IM & IV injections Tourniquet Optional emergency equipment Pulse oximeter Intravenous cannulae Nitrous oxide / oxygen delivery system Laryngoscope Tracheostomy kit
- #9 Criteria for selecting appropriate emergency drugs in general dental practice: Only drugs which are essential for the first-line management of emergencies need to be kept in general dental practice The recommended emergency drugs can be administered by simple (oral, sub-lingual, inhalation or intra-muscular) routes All GDPs should be trained and competent to use the essential emergency drugs Criteria for selecting appropriate emergency drugs in general dental practice: Only drugs which are essential for the first-line management of emergencies need to be kept in general dental practice The recommended emergency drugs can be administered by simple (oral, sub-lingual, inhalation or intra-muscular) routes All GDPs should be trained and competent to use the essential emergency drugs Module one - basic emergency kit (critical drugs and equipment) Module two - noncritical drugs and equipments Module three- advanced cardiac life support Module four - antidotal drugs In each module Injectable drugs Noninjectable drugs Module one:-Emergency equipments Oxygen delivery system Suction & suction tips Tourniquets Syringes Magill intubation forceps Injectable drugs Epinephrine – 1: 1000 Antihistamine – CPM Noninjectable drugs Oxygen – E- Cylinder Vasodialator – NTG, Amyl nitrite Module two:-Injectable drugs Anticonvulsant – Midazolam, Diazepam Analgesic – Morphine Vasopressor – Methoxamine, Phenylephrine. Antihypoglycemic – 50% dextrose, Glucogon. Corticosteroid – Hydrocortisone, Dexamethosone Antihypertensive – Lebetalol, Propronolol Anticholinergic – Atropine Noninjectable drugs Respiratory stimulant – Aromatic Ammonia Antihypoglycemic – Sugar Bronchodilator – Albuterol, Metaproterenol. Emergency equipments Device for cricothyrotomy Artificial airways Laryngoscope & endotracheal tubes Module three:-Essential ACLS drugs include Epinephrine Oxygen Lidocaine Atropine Dopamine Morphine sulphate Verapamil Module four:-Narcotic antagonist – Naloxone, Nalbuphine Benzodiazepine antagonist – Flumazenil Antiemergence delirium drug – Physostigmine Vasodilator – Procaine
- #12 POSITIONING THE PATIENT SUPINE POSITION AVOID TRENDELENBURG POSITION FEET ELEVATED AT 10-15 DEGREES PREGNANT WOMEN – LEFT LATERAL POSITION Assessment of consciousness -Importance? -Three criteria Lack of response to sensory stimulation Loss of protective reflexes An inability to maintain patent airway
- #19 EARLY DEFIBRILLATION AED – Automatic external Defibrillator A battery operated device On applying to victim detects and assesses cardiac rhythm and prompts the user for further action AED BOX contains – AED machine with battery and charger Two self sticking pads with cables & connectors one razor AED MACHINE On/Off switch Plug with flashing light near it Shock delivery button(orange) Speaker & volume control for voice prompt Battery Give ONE shock each time AED advises “SHOCK” Resume CPR immediately- 5 cycles ( 2 min ) starting with chest compressions After 2 minutes, AED will automatically start analyzing again & prompt accordingly Non-shockable rhythm- AED prompts to check for “signs of circulation” - Check Pulse (< 10sec) a) No pulse : continue CPR b) Pulse : discontinue CPR CONTINUE RESUSCITATION UNTIL Qualified help arrives and takes over Victim revives: The victim starts breathing normally Rescuer becomes exhausted
- #20 If the victim responds, position him in the recovery position and monitor breathing until help arrives.
- #26 Synonyms for vasodepressor Syncope: faint, Swoon, Vasovagal Syncope, Neurogenic Syncope PREDISPOSING FACTORS Psychogenic factors • Fright • Anxiety • Emotional stress • Pain • Sight of blood or syringe Nonpsychogenic factors • Sitting in upright position or standing • Hunger • Exhaustion • Poor physical condition • Hot, humid environment • Age between 16 to 35 year • Males Causes of Syncope • Cardiac • Peripheral vascular • Cerebrovascular • Hyperventilation • Hypoglycemia • Seizures CLINICAL MANIFESTATIONS Presyncope : • Early : • feeling of warmth • ashen gray skin • heavy perspiration • feeling bad or faint • nausea • blood pressure approximately at baseline • tachycardia late : • pupillary dilatation • yawning • hyperpnea • coldness in hand and feet • hypotension • bradycardia • visual disturbances • dizziness • loss of consciousness Syncope • irregular, gasping and jerky breathing • or it may cease entirely (respiratory arrest/apnea) • dilated pupils • convulsive movements • bradycardia • low BP • weak and thready pulse • generalized muscle relaxation • fecal incontinence Postsyncope : • Pallor • Nausea • Weakness and Sweating • Mental confusion and disorientation which may persist for 24 hours Cerebral blood flow required for maintaining consciousness is about 30ml of blood per 100 gm of brain tissue per minute. • Brain weighs about 1360 gms. • Normal value of cerebral blood flow per minute is 50 to 55 ml per 100 gm per minute. • So when this decreases, syncope occurs!
- #28 Orthostatic hypotension — also called postural hypotension — is a form of low blood pressure that happens when you stand up from sitting or lying down. Orthostatic hypotension can make you feel dizzy or lightheaded, and maybe even faint. Orthostatic hypotension may be mild and last for less than a few minutes POSTURAL HYPOTENSION • Second leading cause of unconsciousness • Results from failure of baroreceptor reflex mediated increase in peripheral vascular resistance in response to positional changes. • Infrequently associated with fear and anxiety. Predisposing factors Administration and ingestion of drugs • -antihypertensives esp sodium depleting diuretics, Ca channel blockers, ganglion blocking agents • -phenothiazines like chlorpromazine, thioridazine • -tricyclic antidepressants like doxipen, amitryptaline, imipramine • -narcotics like morphine and mepiridine • -antiparkinsonism drugs like levodopa • -Sedatives and tranquilizers • N2O sedation, • Age – more chances with increasing age • Prolonged recumbency and convalescence (as seen in long dental appointments) • Inadequate postural reflex • Pregnancy • Varicose veins in legs • Addison’s disease • Physical exhaustion, fatigue and starvation • Chronic postural hypotension
- #29 Should follow the basic management steps Step 1 to step 7 Definitive management Usually resolve with the above steps. If these does not elevate the BP to acceptable levels, Establish IV line and administer rapid infusion of 500 ml of Ringer’s lactate If the heart rate is less than 60 ATROPINE is given If heart rate normal but BP reduced EPHEDRINE, a vasopressor which acts both on α & β adrenergic receptors is preferred It is important that changes in position from supine to the erect be made slowly. Recheck the BP before the patient leaves the office.
- #30 A condition first recognized by Addison in 1844.It is an uncommon, potentially life threatening and readily treatable condition Cortisol one of the glucocorticoid a product of the adrenal cortex helps the body adapt to stress and is thereby extremely vital to survival. Hypersecretion of cortisol leads to Cushing's syndrome characterized by “buffalo hump” on the back ,raised BP, eosinopenia, lymphopenia. Its not a life-threatening situation Cortisol deficiency on the other hand, may lead to relatively rapid onset of clinical symptoms, quite possibly patient’s death. Primary adrenocortical insufficiency is called Addison’s disease, an insidious and usually progressive disease. Secondary form of the disease is usually produced by administration of exogenous glucocorticosteroids to a patient with functional adrenal glands. In development of acute adrenal crisis, secondary adrenal insufficiency is today a much greater potential threat than is Addison's disease. Acute adrenal insufficiency is a true medical emergency . Death is usually the result of peripheral vascular collapse (shock) and ventricular asystole (cardiac arrest). RULE OF TWOS PT ON 20 mg/DAY of cortisone THERAPY. for2 weeks or longer. Within 2 years. OF DENTAL/SURGICAL T/T
- #31 MANAGEMENT: CONSCIOUS – SEMIRECLINED OXYGEN MONITOR VITALS HYDROCORTISONE 100mg IV OVER 30 SECS, 6-8 HRS DEXAMETHASONE 4mg IV 6-8 HRS EMS TRANSFER TO HOSPITAL UNCONSCIOUS – SUPINE OXYGEN EMS HYDROCORTISONE 100mg IV OVER 30 SECS IV INFUSION OVER 2 HRS EPINEPHRINE 0.5 ml TRANSFER TO HOSPITAL Conscious patient Terminate dental therapy Position the patient ( supine ) Monitor vital signs Summon medical assistance ( patients physician ) Oxygen Administer glucocorticosteroids In a known adrenal insufficiency patient administer 100 mg of hydrocortisone sodium succinate (IV or IM) and repeat every 6 – 8 hours If no prior history, dexamethasone phosphate 4 mg IV every 6 – 8 hours until diagnosis is confirmed by ACTH stimulation test. Additional management 1 liter of normal saline infused in first hour 5 % dextrose added next to help combat hypoglycemia If absence of IV line 1 – 2 mg of glucagon should be administered IM
- #32 SEIZURES • EPILEPSY- “A chronic brain disorder of various etiologies characterized by recurrent seizures due to excessive neuronal discharge” • SEIZURE/ICTUS- “A paroxysmal disorder of cerebral function characterized by a short attack involving changes in the state of consciousness, motor activity, or sensory phenomena” • TONUS- “Neuromuscular dysfunction characterised by sustained contraction and tonicity of all striated muscles” Webster-Merriam’s Medical Dictionary. 12th ed. Baltimore:Williams;2011. “Epilepsy”, “Seizure”, “Tonus”; p166,327,428 CLONUS- “An abnormality in neuromuscular activity characterized by rapidly alternating muscular contraction and relaxation” • POST-ICTAL PHASE- “A phase of centralised neuronal depression following a clonic seizure in which the subject demonstrates generalised muscular relaxation observable as deep slumber” • STATUS EPILEPTICUS- “A prolonged repetitive seizure with no recovery between attacks leading to a life-threatening emergency situation” Webster-Merriam’s Medical Dictionary. 12th ed. Baltimore:Williams;2011.“Clonus”, “Post-Ictal Phase”, “Status Epilepticus”; p98,279,369 ASA CLASSIFICATION OF EPILEPTIC SEIZURES • TYPE I-Absence Seizures/Petit Mal Epilepsy • TYPE II-Myoclonic Seizures • TYPE III-Clonic Seizures • TYPE IV-Tonic Seizures • TYPE V-Tonic-Clonic Seizures/Grand Mal Epilepsy • TYPE-VI-Atonic Seizures 78% 11% 3% 4.8% 1% 2.2% 22 MANAGEMENT OF MEDICAL EMERGENCIES IN DENTAL PRACTICE – 60 PREVENTION • If pt is a known epileptic, make sure he/she has taken their regular dose of anti-convulsant on the day of appointment. • Instruct him/her to alert you as the aura of the impending seizure manifests itself. • Inhalational sedation, based onindividualised severity levels. • Keep life support equipment ready in case of an emergent status epilepticus.
- #33 MANAGEMENT • Self limiting emergency • Remove dangerous objects from the mouth and around the pt.eg. sharp instruments, needles,etc. • Loosen any tight clothing. • Avoid restraining the pt. • In case the ictus fails to subside within a maximum of 10 minutes, declare status epilepticus and proceed with BLS + definitive care. Prodromal stage Terminate the dental procedure Ictal stage Position the patient (supine with legs elevated slightly) Summon medical assistance Protect patient from injury Basic life support as indicated Administer oxygen Monitor vital signs Seizure continues > 5 min Basic life support perform venipuncture, until assistance arrives administer iv anticonvulsant administer 50% dextrose iv definitive management ( phenytoin (15mg/kg) Phenobarbital (10 to 15 mg/kg, Neuromuscular blockade with pancuronium)
- #34 Blood glucose concentrations below levels satisfactory to support the body's need for energy usually defined a blood glucose levels below 3.0mmol per litre. Acute hypoglycaemia may clinically occur in patients who have diabetes and who fail to eat after taking insulin.
- #38 ANGINA PECTORIS Angina is a latin word meaning a spasmodic, cramp like , choking feeling, or suffocating pain. It can be • Stable angina/chronic/classic/exhertional angina • Unstable angina/ crescendo angina, pre infarction angina • Prinzmetal angina/ vasoplastic angina / variant angina • Causes: – Coronary artery atherosclerosis – Coronary artery spasm – Multiple other cardiac and pulmonary etiologies: • Aortic stenosis, cardiomyopathy, pulmonary hypertension or infarction, myocardial disease, pericarditis, mitral valve prolapse, aortic dissection • Clinical characteristics – Poorly localized pain • Usually retrosternal but may occur anywhere from lower jaw to umbilicus – Brief duration • 2-10 minutes – Moderate intensity pain described as squeezing, oppressive, burning or heavy • Clinical characteristics – Precipitated by: • Emotional distress • Physical exertion • Heavy meals • Cold • Walking up stairs or hills – Exacerbated by: • Recumbency – Excluded if: • Pain localized with one finger • Lasts less than 30 seconds or longer than 30 minutes • Pain described as sticking, jabbing, throbbing or constantly severe • Treatment – Stop procedure – Position patient to comfort – Oxygen 2-3 L per NC or face mask – Nitroglycerin 0.4 mg SL • Repeat for 5 minutes • If no response, assume MI or unstable angina • Activate EMS and transfer to hospital Diagnostic approach – Nitroglycerin • Normally relieves pain in 3 minutes or less • Failure to relieve pain after 10 minutes evidence against angina • Failure to relieve pain indicates either unstable• Function of nitroglycerin – Dilates coronary arteries to increase blood flow and improve oxygen d• Dental treatment – Early morning appointments – Short appointments – Stress reduction protocols – Supplemental oxygen – Adequate pain controlelivery to cardiac tissue – Platelet disaggregation angina or myocardial infarction • LA containing vasoconstrictor can be used with proper technique. • Max safe dose of epinephrine for cardiac patients is 0.04 mg which is equivalent to 1 cartridge of 1:50000 conc, 2 cartridges of 1:100000 and 4 cartridges of 1:200000 conc.
- #40 PREVENTION Avoid overstressing the patient Supplemental oxygen during the treatment Pain control during therapy (appropriate use of local anesthesia) Psychosedation Elective dental care is avoided until atleast 6 months after MI IA and PSA nerve blocks should be avoided due to high risk of hemorrhage.
- #41 MANAGEMENT Antiplatelet agents -Clopidogrel (75 mg oral OD) -Ticlopidine (250 mg PO q12 hrs) Dipyridamole (75-100 mg oral TD) Beta-blockers -Propranolol(40 mg oral TD) -Metoprolol (100 mg oral BD) -Atenolol (50 mg oral BD or 100 mg oral OD)
- #45 Airway obstruction ◘ May occur due to: o Pathology on the airway o Dental instruments o Tongue ◘ Patient demonstrates symptoms ranging from coughing, gurgling, gagging, to choking & gasping with pain. ◘ Aspired object may pass into the trachea or oesophagus.
- #46 Is directed at rapid relief of obstruction to prevent cardiopulmonary arrest and anoxic brain damage. • Perform the head tilt and chin lift maneuver if cervical spine trauma is not suspected. • Perform a jaw thrust if cervical spine trauma is suspected. • Attempt to ventilate the patient with a bag-valvemask apparatus. Perform the Heimlich maneuver (subdiaphragmatic abdominal thrust) repeatedly until the object is expelled from the airway. • If the situation cannot be managed, the patient should be referred to a nearby Hospital If the patient is unconscious: • Place the patient in supine position. • Open patient’s airway by using head tilt chin lift technique. • Place the heel of one hand against the victims abdomen in the midline slightly above the umbilicus & well below the xiphoid process. • Place one hand on top of other hand. • Press in to the victims abdomen with quick inward and upward thrust.
- #48 Discontinue the dental procedure and allow the patient to assume a upright position. Establish and maintain a patent airway and administer Beta 2 agonists via inhaler or nebulizer. Administer oxygen if possible If no improvement is observed and symptoms are worsening, administer epinephrine subcutaneously (1:1,000 solution, 0.01 mg/kg of body weight to a maximum dose of 0.3 mg). Begin diligent basic life support. Document in time form the beginning of the event. Alert emergency medical services. Maintain a good oxygen level until the patient stops wheezing and/or medical assistance arrives. Escort patient to hospital as needed
- #49 RECOGNIZE PROBLEM( RESPI.DISTRESS,WHEEZING) DISCONTINUE DENTAL TREATMENT ACTIVATE OFFICE EMERGENCY TEAM POSITION PATIENT UPRIGHT OR BENDING FORWARD WITH ARMS STRAIGHT AHEAD ASCESS A-B-C ( BASIC LIFE SUPPORT) D-DEFINITIVE MANAGEMENT ADMINISTER OXYGEN (5-7 L/MIN) ADMINISTER BRONCHODILATOR – ALBUTEROL (INHALATION) - EPINEPHRINE( ADRENALIN)0.3 MG SC OR IM (BETA 2 ADRENERGIC AGONIST) EPISIDE TERMINATE- CONTI DENTAL TREATMENT-DISCHARGE EPISODE CONTINUES- SUMMON EMS- ADMINISTER PARENTRAL DRUGS ;EPI 0.3 ML IV REPEAT 30 -60 MIN;IF ATTACK IS SEVER GIVE CORTICOSTEROID ( HYDROCORTISONE SODIUM SUCCINATE 100-200 MG IV) – HOSPITALIZE PATIENT
- #51 PREVENTION Exhaled air is inhaled-in again using a paper bag. The point of breathing into a bag is to “rebreathe” your exhaled CO2 to bring the body back to a normal state. Reduce patient’s stress and anxiousness by any means. The operator should stay calm and also make the patient be relaxed MANAGEMENT Administration of Benzodiazepenes: -Diazepam (2-5 mg i.m./i.v. every 3-4 hourly) -Lorazepam (2-3 mg oral per day, BD/TD) -Triazolam (0.25 – 0.5 mg) -Alprazolam (0.25 – 0.5 mg oral TD)
- #52 Toxic effects – these are the result of excessive pharmacological action of drug due to overdosage or prolonged use. • Allergy - Allergy may be defined as a hypersensitive state acquired through exposure to a particular allergen, re-exposure to which produces a heightened capacity to react. • Idiosyncrasy – it is a genetically determined abnormal reactivity to a chemical. • Anaphylaxis – it is a state of rapidly developing immune response to an antigen mediated by IgE antibodies.
- #53 An overdose is when a person ingests or takes in more than normal of recommended or prescribed amount of drug. It can be accidental or intentional. • In a dental practice, most common overdosage is by local anesthesia
- #54 Anaphylaxis is a severe potentially life threatening hypersensitivity reaction to AN ANTIGEN. In the dental setting anaphylaxis may follow administration of a drug or contact with substances used during care. Anaphylaxis is defined as "an acute, potentially life-threatening hypersensitivity reaction, involving the release of mediators from mast-cells, basophils and recruited inflammatory cells. Anaphylaxis is defined by a number of signs and symptoms, alone or in combination, which occur within minutes, or up to a few hours, after exposure to a provoking agent. It can be mild, moderate to severe, or severe. Most cases are mild but any anaphylaxis has the potential to become life-threatening" (World Allergy Organization). Anaphylaxis develops rapidly, usually reaching peak severity within 5-30 min, and may, rarely, last for several days. All dental practitioners should be aware of the diagnosis and management of emergencies such as anaphylaxis that may arise from the use of local anesthetic agents in their clinical set up. Resuscitative drugs such as antihistamine, adrenaline and corticosteroids should be available at chair side for immediate use. All patients must be warned prior to local anesthetic agent administration of the possible danger that follows its use. They should be told to report back immediately to the clinic if a rash should develop. [1] Anaphylaxis may develop immediately and is usually immediately life-threatening due to respiratory embarrassment. Early symptoms and signs include a sensation of warmth, itching especially in the axilla and groin, and a feeling of anxiety and panic. These may progress into an erythematous or urticarial rash, edema of the face and neck, bronchospasm and laryngeal edema. CUSUAL PROGRESSION OF ANAPHYLAXIS Skin Eye , Nose , GI Respiratory system Cardiovascular system
- #55 Adrenaline Adrenaline (epinephrine) intramuscularly (IM) in the anterolateral aspect of the middle third of the thigh (safe, easy, and effective): Adult IM dose 0.5 mg IM (=500 μg = 0.5 mL of 1:1000) adrenaline (epinephrine). >12 years: 500 μg IM (0.5 mL) that is, the same as the adult dose. 6-12 years: 300 μg IM (0.3 mL). <6 years: 150 μg IM (0.15 mL).