Management of medical emergencies in the dental practice

MANAGEMENT OF MEDICAL EMERGENCIES IN DENTAL PRACTICE - 60

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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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Management of medical emergencies in the dental practice

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