Dental Plaque and its role in Periodontal diseases Presented by Deepti Awasthi.
Good Morning. Medical emergencies in the Dental Office Presented by : Deepti Awasthi.
-
Upload
ira-conrad-gordon -
Category
Documents
-
view
215 -
download
0
Transcript of 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
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
Medical emergencies in the dental office
VITAL SIGNS
• The 6 vital signs are as follows :1. Blood pressure2. Heart rate3. Respiratory rate4. Temperature5. Height6. weight
Medical emergencies in the dental office
• 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
• Respiratory rate • Neonate - 40 breaths / min• 1 yr - 24 breaths / min• 3-5 yr - 20 breaths / min• Adult - 16- 18 breaths / min
• Hyperventilation -
Medical emergencies in the dental office
• 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
Medical emergencies in the dental office
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
Medical emergencies in the dental office
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
• 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.
Pediatric basic life support
• Step 7 : assess circulation monitoring heart rate & BPCarotid artery is most reliableIn child, brachial artery is
recommended
• Step 8 : Definitive management
•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
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
Medical emergencies in the dental office
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
Medical emergencies in the dental office
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
Medical emergencies in the dental office
• 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
Medical emergencies in the dental office
Predisposing factors
• 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
Medical emergencies in the dental office
Predisposing factors
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