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D R . S A A D B I N Q A S I M , B . D . S , M S C ( L O N D O N )
R E S E A R C H S C H O L A R
K I N G S A U D U N I V E R S I T Y
C O L L E G E O F A P P L I E D M E D I C A L S C I E N C E S
D E P A R T M E N T O F D E N T A L H E A L T H .
ManagementManagementofof
Medical EmergenciesMedical Emergenciesinin
Dental Pr acticeDental Pr actice
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CONTENTS
What is an Emergency situation. Clinical presentation of emergency Basic Emergency Procedure Approach
Collapse, Acute chest pain, Convulsion, Fainting Pain, Mechanism, Management, Prevention Anaphylactic Reaction. Diabetes, Thyroid crisis
Asthma Angina MI, Stroke
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Common Emergency Situations are:
Fainting (Vasovagal Syncope )
Diabetic Coma
Anaphylactic Shock
Epileptic Seizures
Cardiovascular Collapse (CVC)
Thyroid Crises
Adrenal Crises
Asthmatic Attack
Stroke (Cerebro-vascular Accident, CVA)
What is an Emergency Situation ??
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Sudden loss of consciousness
Chest pain & dyspnea Convulsions (fits)
Clinical Presentation of Emergencies
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Basic Em ergency Pro cedures
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Predisposing factors
Signs & symptoms
Differential diagnosis
(The Main Problem of every Systemic Condition)
Management
Reassess(The General Procedures of Maintaining the Pt Life; VS +
Specific Management for each Condition)
APPROACH
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Vaso-vagal syncope
Acute Hypoglycaemia
Anaphylactic shock
Steroid crisis
Myocardial Infarction
Cardiac Arrest
CVA
COLLAPSE
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Angina
Myocardial Infarction
Asthma
Anaphylactic Shock
ACUTE CHEST PAIN OR DIFFICULTY OF
BREATHING
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EpilepsyEpilepsy
Any other cause of loss of consciousnessAny other cause of loss of consciousness
including faintingincluding fainting
CONVULSIONSCONVULSIONS
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AnxietyAnxiety
PainPain
InjectionsInjections
FatigueFatigue
HungerHunger
FAINTINGFAINTINGPredisposingPredisposing factors:factors:
Str ess ConditionsStr ess Conditions
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PremonitoryPrem onitory dizziness, weakn ess & nauseadizziness, weakn ess & nausea
Pale, cold m oist skinPale, cold m oist skin
Pulse initially slow & w eak, becom ing full &Pulse initially slow & w eak, becom ing full &boundingbounding
MechanismMechanism
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Lay flat & liftLay flat & lift legslegs
Loosen tight clothing aro und neckLoosen tight clothing aro und neck
Give sw eetened drink on regainingGive sw eetened drink on regaining
consciousnessconsciousness Pro longed faint, Atro pine 600 m cg/m l slowPro longed faint, Atro pine 600 m cg/m l slow
IVIV (1(1 ml only)m l only)
ManagementManagement
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Good historyGood history
ReassuranceReassurance
Gener al Anxiety (Stress) ReductionGener al Anxiety (Stress) ReductionProtocolProtocol
W ell fed prior to treatm entW ell fed prior to treatm ent
Glucose dr inkGlucose dr ink
10 m g10 m g Tem azepamTemazepam no ctenocte (prior to appt) & 1(prior to appt) & 1hour before treatmenthour before treatment
Delay the pr ocedur eDelay the pr ocedur e
PreventionPrevention
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Dru gs e.g. penicillinDru gs e.g. penicillin
Insect stingsInsect stings
Foods, nuts, shellfish, m aterialsFoods, nuts, shellfish, m aterials Quicker onset the m ore sever e the reactionQuicker onset the m ore sever e the reaction
W idespread vasodilatation & increase inW idespread vasodilatation & increase incapillar y per m eability, potentially fatalcapillar y per m eability, potentially fatal
hypotensionhypotension
Anaphylactic ReactionAnaphylactic Reaction
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Type I HypersensitivityType I Hypersensitivity
Immediate
IgE mediated Anaphylaxis Urticaria Angio-oedema
Allergic Asthma Rhinitis
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Adverse ReactionsAdverse Reactions
HypersensitivityHypersensitivity
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AngioAngio--oedemaoedema
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Signs & Sym ptoms var iableSigns & Sym ptoms var iable
Rapid weak o r im palpable pulseRapid weak o r im palpable pulse
Facial flushing, itching, tingling, coldFacial flushing, itching, tingling, cold
extremitiesextremities BronchospasmBr onchospasm (wh eezing)(wheezing)
Loss of con sciousnessLoss of con sciousness
Pallor going on to cyanosisPallor going on to cyanosis
Cold, clam m y skinCold, clam m y skin
Facial oedem a & som etim esFacial oedema & som etim es urticariaurticaria
Deep fall in BPDeep fall in BP
AnaphylaxisAnaphylaxis
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Lay flat with r aised legsLay flat with r aised legs
Give Adre naline (1:1000)Give Adre naline (1:1000) 0.30.3--0.5 ml SC or IM0.5 ml SC or IM
Hydrocor tisone 200 m gHydrocor tisone 200 m g i.vi.v.. ChlorpheniramineChlorpheniram ine 1010--20 m g slow20 mg slow i.vi.v..
GiveGive oxygen 6L/m inoxygen 6L/m in & assisted& assisted ventilationventilation
ConsiderConsider Cricothyrotom yCricothyrotomy if NO quickif NO quickimprovementimprovement
Call an am bulanceCall an am bulance
Management of Anaph ylaxisManagement of Anaph ylaxis
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Acute Hypoglycaem iaAcute Hypoglycaem ia
CAUSES:CAUSES:
Overdose of insulinOverdose of insulin
PreventedPrevented fromfrom eatingeating
at expected tim eat expected tim e
MANAGEMENT:MANAGEMENT:
GlucoseGlucosetablets/powdertablets/powder
If unconscious giveIf unconscious give50ml 50% glucose IV50ml 50% glucose IV
SCSC glucagonglucagon 1m g1m g
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The Diabetic PatientThe Diabetic Patient
HypoglycaemiaHypoglycaemia
Rapid onsetRapid onset
IrritabilityIrritability
Moist skinMoist skin
Pulse full &Pulse full & rapidrapid
More comm onMore comm on
Less SevereLess Severe
Easy to be m anagedEasy to be m anaged
HyperglycaemiaHyperglycaemia
Slow onsetSlow onset
Drowsiness/disorientatiDrowsiness/disorientationon
Dry skin & m outhDry skin & m outh
Pulse slow &Pulse slow & weakweak
RareRareM ore Sever eM ore Sever e
Difficult to be managedDifficult to be managed
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Precipita ting Factors:Precipita ting Factors:
InfectionInfection SurgerySurgery
TraumaTrauma
PregnancyPregnancy
Other Physiologic or Emotional StressOther Physiologic or Emotional Stress
THYROID CRISIS (STORM)THYROID CRISIS (STORM)
Sudden, Severe Exacerbation of HyperthyroidismSudden, Severe Exacerbation of Hyperthyroidism
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Manifestations:Manifestations:
HyperpyrexiaHyperpyrexia(Fever)(Fever)
TachycardiaTachycardia AgitationAgitation
PalpitationPalpitation
NausiaNausia, Vom iting, Vom iting
Abdom inal painAbdom inal pain Loss ofLoss of
ConsciousnessConsciousness(Partial or(Partial orComplete)Complete)
Management
Management:Management:
Term inate all dentalTerm inate all dentaltttttt
Summ on m edicalSumm on m edicalassistassist
Adm inister O2Adm inister O2
Monitor VSMonitor VS
Initiate BLS, ifInitiate BLS, ifnecessarynecessary
Start IV line & FluidsStart IV line & Fluids
Transpo rt to ER CareTranspo rt to ER Care
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STEROID CRISISSTEROID CRISISCirculatoryCirculator y CollapseCollapse
The Pt ProblemThe Pt ProblemAdrenocorticalAdren ocor tical Insufficiency: Prim ary (Insufficiency: Prim ary (Addison`sAddison`s Disease); RareDisease); Rare
Secondary (ExogenousSeconda ry (Exogenous tttttt); more com mo n (20 mg); mo re com mo n (20 mg cortisolcortisoldaily/2weeks/year)daily/2weeks/year)
CAUSES: StressStressConditionsConditions
GA
Surgical/Othertrauma
Infection
Other stress
SIGNS & SYMPTOMS Pallor
Weakness
Nausia
Rapid, weak orimpa lpable pulse
Loss of consciousness
Rapidly falling B P
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Lay flat and ra ise legs
Hydr ocor tisone 200m g i.v.
Give oxygen Monitor VS
Start BLS if necessary
Consider other possible reaso ns for loss of
consciousness Am bulance & transfer to hospital
Steroid Cr isis Managem entSteroid Cr isis Managem ent
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Anxiety
Infection or exposure to
specific aller gen Loss or forgetting to br ing
Salbutam ol inhaler
ASTHMAASTHMA
CausesCauses
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BreathlessnessBreathlessness
Expiratory w heezing may beExpiratory w heezing may bedisguised as sh allow breathingdisguised as sh allow breathing
Rapid pulse over 110Rapid pulse over 110
Accessory mu scles ofAccessory mu scles ofrespiration brou ght intorespiration br ought into useuse
Cyanosis of m ucousCyanosis of m ucousm embr ane & nail bedsm embr ane & nail beds
Mental confusionMental confusion
AsthmaAsthma
Signs & Symptom sSigns & Symptom s
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Reassur e the patient
DO NOT lay the patientflat
Give the anti asthm aticdrug nor m ally used
Give oxygen
Give Adren aline
Hydrocor tisone 200 m gi.v.
Monitor VS
If no re sponse to
Salbutam ol 500 m cg
AsthmaAsthma
ManagementManagement
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Acute chest pain w hich mayradiate to left arm orshoulder
Relieved by anti anginaldrug e.g. GTN 0.5m gsublingually
Aspirin 300m g
If sym ptom s do not re solverapidly w ith adm inistrationof GTN, consider it likelythat the patient has suffered
an MI
AnginaAngina
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Severe, crushing retro-sternal pain
Feeling of im pendingdeath
W eak or irr egular pulse
Pain m ay radiate to leftshoulder, arm or jaw
Shock, loss ofconsciousness
Vomiting
MyocardialMyocar dial InfarctionInfarction
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Place patient in a com fortable positionallow ing easy breathing
Send for an ambulance
Give 50/50 Nitrou s Oxide/Oxygen orOxygen only
Aspirin 300m g
Good pain control
Constant reassura nce
MyocardialMyocar dial InfarctionInfarction
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Myocar dial InfarctionMyocar dial Infarction
HypoxiaHypoxia
Anaesthetic overdo seAnaesthetic overdo se AnaphylaxisAnaphylaxis
Severe h ypotensionSevere h ypotension
Cardiac ArrestCardiac Arrest
CausesCauses
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Loss of con sciousness
Absence of ar terial pulse
SUM M ON H ELP Patient on flat, firm sur face
CLEAR AIRW AY (keep patent)
Start CPR
Defibrillation
Transfer patient to h ospital
CARDIAC ARRESTCARDIAC ARREST
Signs, Sym ptom s & Managem entSigns, Sym ptom s & Managem ent
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Severe HeadacheSevere Headache
WeaknessW eakness or Paralysis ofor Par alysis of arm sarmsoror legs of one sidelegs of one side
Unilateral Facial m uscleUnilateral Facial m uscleParalysisParalysis
Difficulty or inability to SpeakDifficulty or inability to Speak
Par tial or Total Loss ofPar tial or Total Loss of
consciousnessconsciousness PatientPatient is veryis very anxious, n eedsanxious, needs
reassura nce and transfer toreassura nce and transfer tohospitalhospital imm ediately, BLS,imm ediately, BLS,Supine Po sitionSupine Po sition BUT H eadBUT H ead
STROKE (CVASTROKE (CVA))
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Predisposing factors:Predisposing factors:
AnxietyAnxiety
HungerHunger MenstruationMenstruation
AlcoholAlcohol
Exter nal stimuli, flashing lightsExter nal stimuli, flashing lightsetcetc
Non com pliance w ithNon com pliance w ithmedicationsmedications
CONVULSIONS (Epilepsy)CONVULSIONS (Epilepsy)
Gran d m al, Petit m al (blank stare)Gran d m al, Petit m al (blank stare)
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W arning cryW arning cry
Imm ediate loss of consciousnessImm ediate loss of consciousness
Rigid (tonic phase )Rigid (tonic phase ) W idespread jerking (W idespread jerking (clonicclonic pha se)phase)
VomitingVomiting
Flaccid after a few m inutesFlaccid after a few m inutes
Consciousn ess is regained a fter a variableConsciousn ess is regained a fter a variableperiodperiod
Patient may rem ain confusedPatient may rem ain confused
ConvulsionsConvulsions
Signs &Signs & Sym ptom s (Gran d m al)Sym ptom s (Grand m al)
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PreventPrevent patients from dam agingpatients from dam agingthemselvesthemselves
Place in Supine positionPlace in Supine position
MaintainMaintain patentpatent airwa yairway
No m edications, aw aitNo m edications, aw ait recoveryrecovery
Recover y position after fits ha ve ceasedRecover y position after fits ha ve ceased
Suctioning & Monitor VSSuctioning & Monitor VS OxygenOxygen
Reassure on recoveryReassure on recovery
After fully recovered requires an e scortAfter fully recovered requires an e scort
ConvulsionsConvulsions
ManagementManagement
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Continuous or repeated convulsions for 15m inutes (patient can have severe ano xia)
Give 10mg Midazolam IV r epeat if no
recover y within 10 m inutes Maintain airw ay & give oxygen
Call an am bulance, tran sfer to h ospital
StatusStatus EpilepticusEpilepticus
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The Recovery Position
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EM ERGENCY KI TEM ERGENCY KI T
TelephoneTelephone
Oxygen cylinderOxygen cylinder
LaerdalLaerdal pocketpocket
mask/mask/AmbubagAm bubag forforhan d ventilationhan d ventilation
Disposable airwa yDisposable airwa y(Sizes1(Sizes1--4)4) GuedelGuedel
Disposable syringesDisposable syringes(2,5,50 m l)(2,5,50 m l)
Disposable needles(23g)
Tourniquet
Cann ulae (20g) Por table suction
equipment
Sphygnomanometer/Autom atic BP m achine
Pulse oximeter
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Adren aline 1:1000, 0.5 m l am poules
Glyceryl trinitra te 500 m cg spray
Aspirin 300 m g
Hydr ocor tisone 100m g vials
Chlorpheniram ine 10 m g
Salbutam ol 100 m cg (m etered inhaler)
Mor phine sulphate tablets 10 m g
Midazolam 10 m g
Glucagon 1 mg am poules
Glucose powd er or dextrose injection
50%
DRUGSDRUGS
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Adequate trainingAdequate training
ProtocolsProtocols
Medical histor yMedical histor y PreventionPrevention
Checks& UpdatingChecks& Updating
Be PreparedBe Prepared