management of medical emergencies in the dental practice
TRANSCRIPT
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MANAGEMENT OF MEDICAL
EMERGENCIES IN DENTAL PRACTICE
Presented by:Dr.Kanika Manral
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CONTENTS
IntroductionTypes of emergenciesPreventionPreparationManagement
SummaryConclusionReferences
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INTRODUCTION
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STRESS!!
SYNCOPE SEIZURE
ANGINA
ASTHMATIC ATTACK
HYPOGLYCAEMIA
CARDIACARREST
ALLERGIES
HYPERVENTILATIONMYOCARDIALINFARCTION
58%
42%
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• Comprehensive medical history• Vigilant observation & prompt
recognition of symptoms of an emergency
• Basic life support• Affiliation to definitive medical care
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COMPREHENSIVE MEDICAL HISTORY
•Thorough questionnaire•Past medical history•Familial disease history•Psychological/ social status•Diet
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BASIC LIFE SUPPORT
•Primary response to all emergencies.•P-A-B-C-D•Position>Airway>Breathing>Circulation>Defibrillation(ACLS)
BLS
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ASA PHYSICAL STATUS CLASSIFICATION
CLASS I: Healthy patient with no systemic disease.
CLASS II: Patient with mild systemic disease with no limits on activity.
CLASS III: Patient with severe systemic disease that limits activity.
CLASS IV: Patient with incapacitating systemic disease that is life threatening.
CLASS V: Terminal moribund patient.
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TYPES OF EMERGENCIES
• UNCONSCIOUSNESS / SYNCOPEVasodepressor SyncopePostural/Orthostatic HypotensionAcute Adrenal InsufficiencyHypoglycemia
• SEIZURES
• RESPIRATORY EMERGENCIESAirway ObstructionHyperventilationAsthma
Contd…
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• CARDIOVASCULAR EMERGENCIESAngina PectorisMyocardial Infarction
• DRUG RELATED EMERGENCIESOverdose ReactionsAllergies
• FUNCTIONAL EMERGENCIESNeedle Stick InjuryNeedle Breakage
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UNCONSCIOUSNESS / SYNCOPE
• “Sudden transient loss of consciousness in which one shows no responsiveness to non-deliberate environmental stimuli”
• Predisposing factors:STRESSIMPAIRED PHYSICAL CONDITIONHYPOGLYCEMIA
Webster-Merriam’s Medical Dictionary. 12th ed. Baltimore:Williams;2011.“syncope”;p.348
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PREVENTION• Via prevention of predisposing
factors:Use of psychosedative drugs
ingestion-alprazolam(4mg), diazepam(5mg)i.m/i.v administration-butorphenol(1mg),
midazolam(5mg)inhalation-N2O+O2 (15%+85%)
Persuasion/Hypnosis
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VASODEPRESSOR SYNCOPE
Stress=Tachycardia=Carotid body & sinus stimulation
Vagal stimulation= Bradycardia,
Vasodilation=Decreased cerebral blood flow
Reflexive response to re-establish cerebral blood
flow=syncope
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POSTURAL /ORTHOSTATIC HYPOTENSION
Pt attains upright position
SBP falls =<60mm of Hg due to ANS response
failure
Cerebral blood flow<critical level
Loss of consciousness
Supination=revival
PATHOLOGY
DrugsProlonged recumbency / convalescenceLate stage pregnancyVaricositiesAddison’s DiseaseSevere exhaustionShy-Drager Syndrome
ETIOLOGY
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ACUTE ADRENAL INSUFFICIENCY
Cause1
•Sudden supplement withdrawal in Addison’s disease pts.
Cause2
•Stress, either physiological or psychological.
Cause3
•Bilateral adrenalectomy pts.
Cause4
•Trauma/thrombosis/tumour of adrenals
Syncope caused due to lack of an adrenaline response in medullary deficient patients resulting from:-
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HYPOGLYCEMIA
Empty stomach/ Morning insulin
Low blood glucose
level=<50mg/100ml
Perilous/ anxious
disposition
Weakness/dizziness, pale skin, depressed
respiration
Unattended>> Loss of
consciousness/syncope
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MANAGEMENT OF SYNCOPE
• Treat the underlying cause• Immediate symptomatic therapy includes:
Recognition of unconsciousness“Shake & shout”Check for protective reflexes
ManagementPosition victim-supinationAssess & open airway-head tilt, chin liftAirway patency, breathing, circulation-look, listen & feelArtificial ventilation & cardiac massage-
cardiopulmonary resuscitation
BLS
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BASIC LIFE SUPPORT
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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
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• 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
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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%
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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 on individualised severity levels.
• Keep life support equipment ready in case of an emergent status epilepticus.
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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.
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RESPIRATORY EMERGENCIES
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AIRWAY OBSTRUCTION
• May occur due to:Pathology in the airwayDental instrumentsTongue
• Patient demonstrates symptoms ranging from coughing, gurgling, gagging to choking & gasping with panic.
• Aspired object may pass into the trachea or the oesophagus
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PREVENTION
Rubber damOral packingChair positionDental assistantMagill’s intubation forceps
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MANAGEMENT• Re-establishment of airway:
NON INVASIVE PROCEDURESoForceful coughingoBack blowsoHeimlich ManeuveroChest thrustoFinger sweeps
INVASIVE PROCEDURESoTracheotomyoCricothyrotomy
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HYPERVENTILATION• Excessive rate and depth of respiration leading
to abnormal loss of carbon dioxide from the blood primarily predisposed to anxiety.
• Characterised by:Rapid short strained breathsCold SweatsPalpitationsDizzinessChest muscle fatigue
• Prevention includes practicing stress reduction protocols and administration of psychosedatives.
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Anxiety
Increased rate and depth of respiration
Increased O2/CO2 exchange by lungs
Excessive CO2 blow off>>paCO2 decreases
Hypocapnia=decreased HCO3 ion conc.
Increased blood pH>>RESPIRATORY ALKALOSIS
PATHOLOGY
Position pt UPRIGHT comfortably
Reassure pt & stabilise vitals
Remove dental materials/instruments from pt’s mouth
Re-establish O2:CO2 ratio by inhalation of exhaled air(85%:15%)
Check vitals & patient status again
Resume treatment procedure
MANAGEMENT
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ASTHMA
• A clinical state of hyper reactivity of the tracheobronchial tree, characterized by recurrent paroxysms of dyspnea and wheezing
• In diagnosed pts, not an emergency.
• Results from constriction of smooth muscles of the tracheobronchial tree resulting from infection, inflammation or a genetic disposition.
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Predisposing factors-INTRINSIC & EXTRINSICEXTRINSIC OR ALLERGIC ASTHMA • The allergens may be airborne – house dust,
feathers, animal dander, furniture stuffing, fungal spores, or plant pollens.
• Food and drugs – cow’s milk, egg, fish, chocolate, shellfish, tomatoes, penicillins, vaccines , asprin, and sulfites.
• Type I hypersensitivity reaction – Ig E antibodies produced in response to allergen
• Approximately, 50% asthmatic children become symptomatic before reaching adulthood
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• Usually develops in adult age > 35 years
• Non allergic factors – respiratory infection, physical exertion, environmental and air pollution, and occupational stimuli.
• Psychological and physiologic stress can also contribute to asthmatic episodes.
• Acute episodes are usually more fulminant and severe than those of extrinsic asthma. Long-term prognosis also less optimistic.
INTRINSIC OR IDIOSYNCRATIC OR NON-ATOPIC ASTHMA
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MANAGEMENTRecognise symptoms
Stop dental procedure
Position pt upright or bending forwards with arms straight ahead
Administer bronchodilator
Episode terminates?
YES NO
Continue dental procedure Declare status asthmaticus
Summon EMS
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CARDIOVASCULAR EMERGENCIES
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Heart recieves blood via coronaries
Coronaries narrow down due to cholesterol
Reduced nutrition to respective cardiac muscle
Treatment anxiety leads to palpitations
Greater oxygen requirements for greater pumping
Acute Coronary Syndrome(ACS)
ANGINA PECTORIS
MYOCARDIAL INFARCTION
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ANGINA PECTORIS• Definition- “A condition marked 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 (classic or exertional) Variant (prinzmetal , vasospastic) Unstable (crescendo, acute coronary insufficiency)
• Prevention includes stress reduction protocol, reassurance & psychosedation.
Webster-Merriam’s Medical Dictionary. 12th ed. Baltimore:Williams;2011. “Angina Pectoris”; p73
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Recognize problem (chest pain – angina attack)Discontinue dental treatment
Activate office emergency teamP – Position, patient comfortably usually upright
A → B → C –Assess and perform BLS
D – definitive management
HISTORY OF ANGINA PRESENT NO HISTORY OF ANGINAAdminister vasodilator and O2 Activate EMS
Transmucosal nitroglycerine spray O2 and nitroglycerine
Or sublingual nitroglycerine tablet Monitor and record 0.3 – 0.6 mg for every 5 min (3 doses)
IF PAIN RESOLVES IF PAIN DOES NOT RESOLVE
continue with dental procedure summon medical care Administer aspirin Continue to monitor and
record vital signs
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MYOCARDIAL INFARCTION
• DEFINITION- “A clinical syndrome caused by deficient coronary arterial blood supply resulting in ischaemia to a region of the myocardium and causing cellular death and necrosis.”
• Predisposing Factors:– Atherosclerosis and coronary artery disease– Coronary thrombosis, occlusion and spasm– Males– 5th and 6th decades of life– Undue stress
Webster-Merriam’s Medical Dictionary. 12th ed. Baltimore:Williams;2011. “Myocardial Infarction”; p197
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DENTAL CONSIDERATIONS• Avoid overstressing the patient
• Supplemental oxygen via nasal cannula or nasal hood during the treatment – 3-5 L/min and 5 – 7 L/min
• Pain control during therapy – appropriate use of local anesthesia – smaller dose with maximum effect – slow administration
• Psychosedation – N2O – O2 is preferable
• It is strongly recommended that elective dental care is avoided until at least 6months after MI
• Inferior alveolar NB and Posterior superior alveolar NB – risk of hemorrhage – should be avoided
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MANAGEMENT
• Protocol common for both ACS outcomes
• NOTE: In a patient experiencing chest pain for the very first time, summon medical assistance immediately before any self-support measures.
• Thereafter, continue with immediate emergency protocol as with AP.
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PORTABLE AUTOMATIC EXTERNAL DEFIBRILLATOR(AED)
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DRUG RELATED
EMERGENCIES
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OVERDOSE REACTIONS
• In a dental practice, commonest overdosage>>LA
• Predisposing factors for over dosage:Pt age/body wtRoute of administrationPresence of vasoconstrictorType of local anaesthetic
• Drug dosage formulation vital DH X
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CLINICAL MANIFESTATIONS
• Confusion, talkativeness, blurred speech
• Muscular twitching, facial tremor• Headache, tinnitus• Drowsiness, disorientation• Elevated BP,HR,RR• If uncontrolled, generalised tonic clonic
seizures, generalised CNS carbopathy.
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MANAGEMENT
• Administer basic life support• 100% oxygen, anticonvulsants• Allow recovery to occur• In case of continuation of symptoms,
summon EMS.
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ALLERGY
• DEFINITION- “A hypersensitive state of skin and various mucosae acquired through exposure to a particular allergen, reexposure to which produces a heightened emergent capacity to react”
• Occuring via expression of IgE in response to allergen exposure
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MANAGEMENT
• Reassure pt.• Initiate basic life support as needed.• Administer antihistaminics
(diphenhydramine 50mg), epinephrine 0.123-0.3ml of 1:1000 i.m /s.c
• Monitor vitals regularly.• Summon EMS
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EMERGENCY DRUG KIT
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FUNCTIONAL EMERGENCIES
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NEEDLE STICK INJURY• Injury made with any sharp instrument, not just.
• Encountered more commonly by the practitioner.
• Stop procedure immediately.
• Wash skin with disinfectant.
• Treat with running water and encourage bleeding
• Dry area and cover with antiseptic dressing
• Recording medical history vital in case of an exposed needle situation.
• Seek antidotal vaccination or treatment if necessary.
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NEEDLE BREAKAGE
• Invariably associated with faulty techniques such as:bending the needle while administering LA inserting the needle upto the hubdirecting the needle against resistance
• May also occur if pt jerks head during administration.
• Most commonly with IANB.• Elasticity of soft tissue produces rebound,
burying the fragment within.
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MANAGEMENT
• Inform pt of the occurance, tell him/her to remain calm, keep mouth open and refrain from any jaw movements.
• Retrieve the fragment, if visible, with a haemostat.
• A buried fragment needs to be located ASAP using radiographs or CT scans & retrieved surgically.
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SUMMARY & CONCLUSION
• ALWAYS BE PREPARED• Prompt recognition and efficient
management of medical emergencies by a well-prepared dental team can increase the likelihood of a safe & satisfactory outcome.
• Basic life support training- A MUST• As always, prevention is better than
cure.
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REFERENCES
• Malamed SF. Medical Emergencies in the Dental Practice. 4th ed. Baltimore: Elsevier; 2007
• Limmer D, O’Keefe M. Emergency Care. 10th ed. St.Louis: Macmillan Co; 2010
• Malik NA. Textbook of Oral & Maxillofacial Surgery. 2nd ed. New Delhi: Jaypee Brothers Pub; 2008
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• Haas DA. Management of Medical Emergencies in the Dental Office: Conditions in Each Country, the Extent of Treatment by the Dentist. J Anaesth Prog 2006;53(2):20-24
• Geller S, Malamed SF. Knowing Your Patient. J Am Dent Assoc 2010;104:3S-7S
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