Good Morning. Medical emergencies in the Dental Office Presented by : Deepti Awasthi.

Good Morning

Medical emergencies in the Dental Office

Presented by :Deepti Awasthi

CONTENTS

• Introduction• Prevention• Preparation• Unconsciousness - vasodepressor

syncope - postural

hypotension - acute adrenal

insufficiency

• Respiratory disease - Airway obstruction - Asthma• Altered consciousness Diabetes Mellitus :

hyperglycemia

hypoglycemia• Seizures• Allergy• Chest pain• Conclusion• Refernces

INTRODUCTION

PREVENTION

• Acc. To Mc Carthy , a complete system of physical evaluation for all prospective dental patients can prevent 90% of life threatening situation.

1. Physical Evaluation

• Medical history questionnaire• Physical examination • Dialogue history

2. Psychological Evaluation

Medical emergencies in the dental office

Physical examination consist of :

• Monitoring of vital signs• visual inspection• function tests• auscultation


VITAL SIGNS

• The 6 vital signs are as follows :1. Blood pressure2. Heart rate3. Respiratory rate4. Temperature5. Height6. weight


• Blood pressure

• Patient arm should rest at the level of the heart, relaxed, slightly flexed & supported on a firm surface.

• Lower in younger

• Pulse • Adults – 60- 80 beats / min• Child - 80-110 beats / min• Common site : radial artery on the

thumb side of wrist.• Carotid artery can also be checked at

the side of the neck.• Thumb should not be used to monitor

a pulse• In infants : brachial artery is

preferred in the upper arm Textbook of pediatric dentistry -S G Damle

Brachial artery Carotid artery

• Respiratory rate • Neonate - 40 breaths / min• 1 yr - 24 breaths / min• 3-5 yr - 20 breaths / min• Adult - 16- 18 breaths / min

• Hyperventilation -


• Temperature • 36 - 37*C / 97 - 99*F• The thermometer ,sterilized &

shaken down is placed under the tongue.

• It should remain in the mouth for 2 mins

• Fever – 99.6*F or 37*C.

Textbook of pediatric dentistry -S G Damle

• Height & weight

• Gross obesity & extreme underweight may indicate of an active pathologic process.

Textbook of pediatric dentistry -S G Damle

ASA physical status classification system

(1962, American Society of Anesthesiologists)• ASA I : A normal healthy patient without

systemic disease• 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 E : Emergency operation of any variety; E precedes the number, indicating the patients physical status( ASA E-III)

Arathi Rao

Stress reduction protocol

Recognition of medical risk and anxiety Medical consultation Premedication Appointment scheduling Minimized waiting time Psychosedation during therapy Adequate pain control during therapy Duration of dental treatment Postoperative control of pain and anxiety


PREPARATION

1. 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

2. Office preparation should include:• Access to emergency assistance• Availability of emergency drugs and

equipment

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 2 categories :

a) Injectable drugs

b) Noninjectable drugs

Emergency Drugs and Equipments


MODULE - 1Injectable drugs

1. Epinephrine – 1: 10002. Antihistamine – 10 mg /ml

Noninjectable drugs3. Oxygen –1 E- Cylinder4. Vasodialator – Nitro glycerine5. Bronchodilator – Albuterol6. Antihypoglycemic – sugar7. Antiplatelet - Aspirin

Emergency equipments8. Oxygen delivery system9. Suction & suction tips10. Tourniquets11. Syringes12. Magill intubation forceps

MODULE - 2Injectable drugs

1. Anticonvulsant – Midazolam2. Analgesic – Morphine 3. Vasopressor – Methoxamine4. Antihypoglycemic – 50% dextrose solution5. Corticosteroid – Hydrocortisone6. Antihypertensive – Esmolol 7. Anticholinergic – Atropine

Noninjectable drugs

8. Respiratory stimulant – Aromatic Ammonia9. Antihypertensive – Nifedipin

Emergency equipments

10. Device for cricothyrotomy11. Artificial airways12. Equipment for endotracheal intubation.

MODULE-3

1. Epinephrine 2. Oxygen 3. Lidocaine4. Atropine5. Dopamine6. Morphine sulphate7. Verapamil

Module -4

1. Opioid antagonist – Naloxone,

2. Benzodiazepine antagonist – Flumazenil

3. Antiemergence delirium drug –

Physostigmine

4. Vasodilator – Procaine

UNCONSCIOUSNESS

• Common faint , was the medical emergency most often reported, accounting for more than 50% of all emergency situations

• Predisposing factors : 1)Stress 2)Impaired physical status 3)Administration or ingestion of

drugsMedical emergencies in the dental office

Possible causes of unconsciousness in dental office:

1. Vasodepressor syncope2. Drug administration / ingestion3. Orthostatic hypotension4. Epilepsy5. Hypoglycemic reaction6. Acute adrenal insufficiency7. Acute allergic reaction8. Acute myocardial infarction9. Hyperglycemic reaction10.Hyperventilation syndrome.

• Prevention 1. Can be prevented by a thorough

pretreatment medical & dental evaluation of the patient

2. Use of Sedation techniques3. Sit-down dentistry, with patients in

supine or slightly recumbent position.

MANAGEMENT

• 2 objectives :• A. Recognition of unconsciousness• B. Management of unconscious

victim.

• RECOGNITION : Step 1 : Assessment of consciousness. 3 Criteria should be used :

– Lack of response to sensory stimulation – Loss of protective reflexes– inability to maintain patent airwayPain is another stimulus that may be

used.Step 2 :terminate dental procedureStep 3 : summoning of help

• MANAGEMENT• Step 4 : position victim

• Step 5 : assess & open airway

Head tilt – chin lift Jaw thrust

Pediatric basic life support

• Step 6 a : assess airway patency & breathing

• Step 6 b : Artificial ventilation

May be provided by 3 ways :1. Exhaled air ventilation2. Atmospheric air ventilation3. Oxygen- enriched ventilation

Exhaled air ventilation - 16% to 18% of inspired oxygen & maintains an oxygen saturation 97% to 100% which is adequate to maintain life.

• Mouth to mouth breathing• Mouth to nose breathing

Adults - 10-12 times / minute Children & infants - 20 times / minute

MEDICAL EMERGENCIES IN the dental office

Atmospheric air ventilation – delivers 21% of oxygen

Self inflating bag-valve-mask devices (BVM) : Ambu bag Pulmonary manual resuscitaton

Artificial airways

Oxygen enriched ventilation- Includes portable E cylinder with adjustable oxygen flow (10-15L/min) & a face mask , an E cylinder with a demand

valve mask unit.


• Step 7 : assess circulation monitoring heart rate & BPCarotid artery is most reliableIn child, brachial artery is

recommended

• Step 8 : Definitive management

Recovery position


•If there are no signs of life•Start chest compression.

• Combine rescue breathing and chest compression.•For all children, compress the lower half of the sternum:

• To avoid compressing the upper abdomen, locate the xiphisternum by finding the angle where the lowest ribs join in the middle. Compress the sternum one finger’s breadth above this.• Compression should be sufficient to depress the sternum by at least onethird of the depth of the chest.• Don’t be afraid to push too hard. Push “hard and fast”.•Release the pressure completely, then repeat at a rate of 100 – 120/ min•After 15 compressions, tilt the head, lift the chin, and give two effective breaths.• Continue compressions and breaths in a ratio of 15:2.•In children – 5:1

2010 resuscitation guidelines


• Automated external defibrillators

• successful use of AEDs in children less than 8 years

• capable of identifying arrhythmias accurately in children and are extremely unlikely to advise a shock inappropriately.

• purpose-made paediatric pads or programmes- 50 -75 J

2010 resuscitation guidelines

Automated external defibrillator

VASODEPRESSOR syncope

• Common faintA sudden, transient loss of consciousness that usually

occurs secondary to a period of cerebral ischemia.Synonyms:

Atrial bradycardia Benign faint Neurogenic syncope Psychogenic syncope Simple faint Swoon Vasodepressor syncope Vasovagal syncope


Predisposing factors

• Psychogenic :

• Fright• anxiety• stress• unwelcome news• pain• sight of blood or

instruments

• Non –Psychogenic

• standing position• hunger• missed meal• exhaustion• poor physical condition • hot, humid environment.• Male• 16-35 years


Earlyo Feeling of warmtho Palloro perspirationo Nauseao BP at baselineo Tachycardia

Lateo Pupillary dilationo Yawningo Hypernoeao Cold hands & feeto Hypotension o Bradycardiao Visual disturbanceso Dizzinesso Loss of consciousness

• Clinical manifestations:

Grouped into 3 definite phases :1. Presyncope2. Syncope3. Postsyncope

Presyncope :

• Syncope :• Breathing may become – irregular, jerky, gasping quiet , shallow cease entirely• Pupils dilate• Convulsive movements & muscular

twitching• Bradycardia (<50 beats /min)• Low BP(30/15mm Hg)• Weak & thready pulse• Fecal incontinence may occur

Postsyncope:

• Pallor• Nausea• weakness • sweating • Short period of confusion or disorientation. • BP and heart rate returns toward the baseline.• Pulse becomes stronger.

MANAGEMENT

• PRESYNCOPE :• Step 1 - position• Step 2 - A-B-C• Step 3 - D (definitive care) proceed if both doctor &

patient feel otherwise treatment should be postpond


• SYNCOPE :• Definitive care : assess consciousness Activate office emergency systemPosition patient supine with feet elevated slightly A B C D – initiate definitive care administer oxygen monitor vital signs administer aromatic ammonia administer atropine if bradycardia persistsPost syncopal recovery delayed recoveryPostpone treatment activate emergency medical

services determine precipitating factorsMedical emergencies in the dental office

POSTURAL HYPOTENSION

• 2nd leading cause of syncope• A disorder of autonomic nervous

system in which syncope occurs when the patient assumes an upright position

• result of a failure of the baroreceptor -reflex -mediated increase in peripheral vascular resistance in response to positional changes



• Drug administration & ingestion• Prolonged periods of recumbancy • Inadequate postural reflex• Pregnancy (later stages)• Advanced age• Varicose veins• Addison’s disease• Physical exhaustion • Starvation• Chronic Postural Hypotension

Clinical manifestation

• Drop in blood pressure & lose consciousness when they stand or sit upright

• Do not exhibit the prodromal signs & symptoms of vasodepressor syncope

• Consciousness returns rapidly once patient is returned to the supine position

• Dental consideration :• Slowly reposition patient upright• Stand nearby as patient stands after

treatmentMedical emergencies in the dental office

Acute adrenal insufficiency

• Uncommon & potentially life threatening but readily treatable

• Addisson in 1844• Incidence – 0.3 & 1 per 100,000

individuals• Clinical manifestation do not develop

until 90% of cortex is destroyed.• True medical emergency



1. Sudden withdrawal of steroid in patient with Addison's disease.

2. Following stress, such as physiologic or psychologic stress.

3. Following bilateral adrenalectomy.4. Sudden destruction of pituitary gland.5. Injury to both adrenal gland by trauma,

hemorrhage, infection, thrombosis or tumor.

CLINICAL MANIFESTATIONSWeakness and fatigueAnorexiaWeight lossHyperpigmentation HypotensionNausea, vomitingAbdominal painCraving DiarrhoeaConstipationSyncopeVitiligo Musculoskeletal complaintsLethargyConfusionPsychosis

• Conscious patientTerminal dental therapyPosition the patient ( supine )Monitor vital signsSummon medical assistance ( patients physician )Obtain emergency kit & oxygenAdminister glucocorticosteroids

i. If a known adrenal insufficiency patient administer 100 mg of hydrocortisone sodium succinate (IV or IM) and repeat every 6 – 8 hours

ii. If no prior history, dexamethasone phosphate 4 mg IV every 6 – 8 hours until diagnosis is confirmed by ACTH stimulation test.

Additional management

1. Provide BLS2. 1 liter of normal saline infused in first hour3. If absence of IV line 1 – 2 mg of glucagon should be

administered IM

Management

• Unconscious patient

Recognize unconsciousnessPosition the patientProvide BLS Definitive management

1. Oxygen2. There will be no response by patient to

ammonia3. Administer 100 mg hydrocortisone IV or IM

should be injected over 30 seconds4. 1 liter of normal saline infused in first hour

Transfer to hospitalMEDICAL EMERGENCIES IN dental office

References

• Medical emergencies in the dental office: Stanley F Malamed , 5th ed.

• Textbook of pediatric dentistry ; S.G. Damle, 3rd ed.• Textbook of pediatric dentistry ; Arathi rao• Pediatric basic life support; 2010 resuscitation

guidelines• Pediatric basic life support; circulation 2005 ,112 (iv)• Medical emergencies in pediatric dentistry ; annals &

essence of dentistry

Good Morning. Medical emergencies in the Dental Office Presented by : Deepti Awasthi.

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