Medical Emergencies · CONTENTS • Introduction • Objectives • Prevention of medical emergency...

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MEDICAL EMERGENCIES

Transcript of Medical Emergencies · CONTENTS • Introduction • Objectives • Prevention of medical emergency...

Page 1: Medical Emergencies · CONTENTS • Introduction • Objectives • Prevention of medical emergency • Preparation for emergencies • Recommended dental office emergency drugs •

MEDICAL

EMERGENCIES

Page 2: Medical Emergencies · CONTENTS • Introduction • Objectives • Prevention of medical emergency • Preparation for emergencies • Recommended dental office emergency drugs •

CONTENTS

• Introduction

• Objectives

• Prevention of medical emergency

• Preparation for emergencies

• Recommended dental office emergency drugs

• Suggested dental office emergency equipment

• Basic life support

• Commonly occurring medical emergencies

• Conclusion

• Refrences

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• Dorland’s medical dictionary, defined medical

emergency as a sudden, urgent, usually unforeseen

occurrence requiring immediate action.

• Medical emergencies in dental practice are not an

uncommon occurrence, it invariably occurs when least

expected.

• Simple protocols that are followed will help the dentist

to be in control with situation.

INTRODUCTION

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OBJECTIVES

❖Recognize a medical emergency.

❖Asses and manage various life-threatening medical

emergencies.

❖Contempt in basic life support (BLS)

❖Know what equipments and medications be kept in an

emergency kit.

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PREVENTION OF MEDICAL

EMERGENCY

• Complete medical and dental history

• Physical examination

• Medical consultation if required

• Patient monitoring

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PREPARATION FOR

EMERGENCIES

• A functioning dental office emergency team.

• The ability to properly perform basic life

support.

• Access to emergency medical assistance.

• The availability of emergency drugs and

equipment.

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Malamed SF. Emergency Medicine in Pediatric Dentistry: Preparation and Management.

C.D.A. journal. 2003; 31.

RECOMMENDED DENTAL OFFICE EMERGENCY

DRUGS

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• The level of medical care which is used

for victims of life-threatening injuries until

they can be given full medical care at a

hospital.

BASIC LIFE SUPPORT

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Regardless of emergency, discontinue

dental procedure immediately & follow

pattern of

1. Circulation evaluation to

ensure that the vital organs

are being supplied adequately.

2. Airway patency and

maintenance.

3. Breathing assessment of the

child.

4. Definitive treatment.

1

2

4

3

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Basic Life Support/Cardiopulmonary Resuscitation. American Academy Of

Pediatric Dentistry, 2015.

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Circulation

Airway

Management

Head

tilt chin

lift

Jaw

thrust

Breathing

▪ Pinch nose

▪ Take normal breath

▪ Place lips over mouth

▪ 1 breath every 6 sec

▪ Blow until chest rises

▪ Allow chest to fall

▪ Repeat

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CPR FOR CHILDREN

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COMMONLY OCCURRINGMEDICAL EMERGENCIES

1. Allergy or Allergic reaction

2. Anaphylaxis

3. Acute asthmatic attack.

4. Hypoglycemic shock

5. Airway obstruction

6. Seizures

7. Syncope

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1. ALLERGY / ALLERGIC REACTION

• Allergy-hypersensitive state results from exposure to allergen.

• Range from immediate-life threatening condition seen within

seconds or delayed type reaction which may manifest hours

or days after exposure.

• Urticaria-itching

• Angioedema

• bronchospasm,

• Conjuctivitis and

watering of eyes

• Hypotension

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2. ANAPHYLAXIS

• They pose greatest risk to the pediatric patient and is

of greatest concern to dental staff.

• Result from drug administration or reaction to an

allergen (impression material or other materials)

• Most life threatening and dramatic allergic reaction.

• Death can occur in minutes if not treated

appropriately.

• Reactions affect skin, smooth muscle, respiratory and

cardiovascular system

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• Anaphylactic shock occurs when consciousness lost as

result of hypotension from an anaphylactic reaction.

• Symptoms begin with skin, eyes, nose then GI system,

respiratory system, finally CVS symptoms develop.

• Prompt therapy can stop reaction

Cardiac arrest

Cardiovascular shock

Including pallor,

sycope, tachycardia,

weak pulse-syncope

Respiratory-

sneezing,

coughing,

wheezing,

Rhinitis

bronchospasm,

laryngospasm

Skin-

Urticaria-itching

Angioedema

Rash Gastrointestinal-

Nausea

Vomiting,

Abdominal cramps

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MANAGEMEN

T

Acute Reaction:

• Basic Life Support

• Epinephrine, injection i/m,1:1000 in 1 mg vials

• If no improvement then 0.3-0.5mg im/sc repeat every 5-10

minutes. Pediatric dose- 0.2-0.3 mg

• Oxygen is administered continuously.

• Corticosteroid-high dose is given if asthma, edema or

pruritis.

• Isotonic solutions for hypotension

• Beta-adrenergic agonist in bronchospasm

• Activate EMS (Emergency life support)

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3. ACUTE ASTHMATIC

ATTACK

• Generalized contraction of smooth muscles of bronchi

and bronchioles.

• Characterized- increased irritability of tracheo bronchial

tree to various stimuli including pollen, stress, cold,

upper respiratory tract infections, animal fur.

• Bronchospasm, mucosal edema and intra luminal

secretions lead to airway obstruction. Triggered by

emotional stress and anxiety during the course of

treatment.

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Recognition➢ Attack may be very mild or present

as STATUS ASTHAMATICUS

➢Expiratory or inspiratory Wheezing

➢ Nonproductive Cough

➢ Diaphoretic

➢ Cyanosis of nail beds

➢ Chest tightness

➢ Chest congestion

➢ Fatigue

➢ Panic, Anxious, confused.

➢Thick stringy mucous at

termination of intense coughing

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TREATEMEN

TTreatment:

➢ Discontinue dental treatment.

➢ Sitting position is most comfortable

➢ Use of bronchodilators supplemented with oxygen

and hydration. Supplemental oxygen at 10L/min.

➢ Patient to use his own inhaler, if available with him

➢ Adrenaline 1:1000, 0.15 ml SC/IM

➢ Corticosteroids if required.

➢ If no improvement call EMS

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▪ Atropine and antihistaminic drugs also tend to dry

secretions.

▪ Aspirin should be avoided in asthmatics as this can make

the conditions worse in certain patients.

▪ A preoperative history of

✓Severity

✓Medicines required

✓Degree of control

✓Recent visit to emergency room to be taken.

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4. AIRWAY OBSTRUCTION

May be caused by-

✓ Swelling of neck owing to infection or trauma

✓ Tumors growing in the air passage

✓ Unconsciousness, causing tongue to fall posteriorly

✓ Obstruction from a foreign body

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Obstruction from a foreign body may occur in……..

• Waiting room owing to food or partial denture

• In the operatory room from various oral surgical

instruments, materials, tooth or vomitus.

• In a restaurant (café coronary)

More likely to occur when consciousness is reduced

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Recognition:

• Disappearance of foreign body from oral cavity + signs of

laryngeal and bronchial irritation. Consider to have passed into

respiratory passage until proved other wise.

Partial obstruction:

• Gag, choking, coughing or wheeze in an attempt to eject object.

Advise radiographs of chest & abdomen to confirm location.

Complete obstruction:

• No noises are made although patient is attempting to cough or

talk, showing signs of choking, suprasternal & intercostal

retraction

• If foreign body located in trachea or bronchi. Should be referred

immediately for removal by bronchoscopy or thoracotomy.

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SIGNS AND SYMPTOMS-

• First Phase (1-3 min) : Conscious, universal chocking,

struggling, paradoxical respirations without air movement or

voice, increased BP & Heart rate.

• Second Phase (2-5 min) : Loss of consciousness, decreased

respiration, BP, heart rate.

• Third Phase (>3-5 min) : Coma, absent vital signs, dilated

pupils.

PREVENTION

• Rubber dam

• Oral/ throat packing (used in sedation or GA)

• Ligature (small instruments secured by tying)

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TREATMENT-

1. Lean patient over chair & pound firmly on back try to

dislodge foreign body (small children may be held upside

down by legs & sharp blows rendered to back).

2. If unsuccessful. Keep patient supine on floor/Trendelenburg

position if in dental chair, with head to side and mouth open.

Middle and index fingers should be placed into pharynx and

swept laterally in attempt to remove object.

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3. Try to remove object using laryngoscope and Magill

forceps if possible

4. Consider Heimlich procedure (1975): Procedure takes

advantage of remaining air within lungs and by

forcefully compressing the lungs, increases air pressure

within trachea, thus ejecting the offending bolus out.

(like a “cork from a champagne bottle”) (avg. airflow

rate of 205 L/min and pressure 31mm Hg, expelling an

avg. volume of 0.94 L of air in approx. ¼ sec).

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Page 31: Medical Emergencies · CONTENTS • Introduction • Objectives • Prevention of medical emergency • Preparation for emergencies • Recommended dental office emergency drugs •

5. HYPOGLYCEMIA

• Condition of acutely decreased blood sugar. Life

threatening- more critical than hyperglycemia in emergency

situation. Must be treated rapidly.

• Children suffer from diabetes mellitus type 1.

• Blood (venous) glucose level falls to < 50mg/100ml in

adults & <40mg/100ml in children.

• CAUSES- Intake of too little food, Impaired gastric

emptying. Exercise Is attempted but no reduction in insulin

dose.

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Signs And Symptoms-

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• Terminate procedure.

• For conscious patient, glucose/ carbohydrate to be given in

3-4 ounces (1ounce= 28gms) every 5-10 min until

symptoms disappear.

• For unresponsive conscious patient, Glucagon 1mg IV/IM

or 50ml of 50% dextrose IV over 2-3 mints.

• Oral-paste or drink.

• Perform BLS.

• Activate EMS.

Page 34: Medical Emergencies · CONTENTS • Introduction • Objectives • Prevention of medical emergency • Preparation for emergencies • Recommended dental office emergency drugs •

6. SYNCOPE

• Sudden, transient loss of consciousness that usually

occurs secondary to a period of cerebral ischemia.

• Predisposing factors-

1. Psychogenic factors- Fright, anxiety, emotional stress,

pain, site of blood

2. Non- psychogenic factors- Erect sitting or standing

posture, hunger from dieting or a missed meal,

exhaustion, poor physical condition, male gender.

Page 35: Medical Emergencies · CONTENTS • Introduction • Objectives • Prevention of medical emergency • Preparation for emergencies • Recommended dental office emergency drugs •

PATHOPHYSIOLOGY-

• Dilation of blood vessels in skeletal muscle and

splanchnic region.

• A fall in peripheral resistance with decreased venous

return to the heart. This leads to fall in arterial pressure.

• Vagal reflexes are activated, causing bradycardia,

reduction in cardiac output, further reduction in BP, all

leading to decreased cerebral perfusion.

VASOVAGAL ATTACK- rare entity in children as:

• Children keep moving their extremities

continuously.

• The parasympathetic tone in a child is higher.

• Children are more expressive.

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Clinical manifestations-

EARLY

• Feeling of warmth

• Loss of color, pale.

• Heavy perspiration

• Reports of feeling bad

• Nausea

• BP slightly lower

• Tachycardia

LATE

Pupillary dilation

Yawning

Hyperpnea

Cold hands and feet

Hypotension

Bradycardia

Visual disturbance

Dizziness

Loss of consciousness

Page 37: Medical Emergencies · CONTENTS • Introduction • Objectives • Prevention of medical emergency • Preparation for emergencies • Recommended dental office emergency drugs •

EMERGENCY MANAGEMEMT-

First step is PREVENTION-

• Proper positioning

• Anxiety relief

• Dental therapy consideration

Second step is MANAGEMENT-

• Discontinue treatment

• Assess the level of consciousness: Patient’s lack of response to

sensory stimulation

• Activate the office emergency system: Call for help and

emergency drug kit should be available

• Position of patient: Proper supine position with feet elevated.

• Assess airway and circulation

• Provide definitive care: Give oxygen, monitor vital signs, No

drug treatment usually indicated.

• Also loosen clothing if binding & cold towel at back of neck

Page 38: Medical Emergencies · CONTENTS • Introduction • Objectives • Prevention of medical emergency • Preparation for emergencies • Recommended dental office emergency drugs •

7. SEIZURES

• Group of disorders of cerebral functions characterized by

chronic, recurrent, paroxysmal discharge of cerebral

neurones.

Primary

generalized;

➢Tonic clonic

➢Absence

➢Infantile

spasm

➢myoclonic

Partial/focal

seizures

➢Motor

➢Sensory

➢Visual

➢Versive

➢Temporal

Page 39: Medical Emergencies · CONTENTS • Introduction • Objectives • Prevention of medical emergency • Preparation for emergencies • Recommended dental office emergency drugs •

Recognition-

• A positive medical history for seizures.

• Typical pre seizure appearance or signs which differ in

different individuals, - aura, may be seen.

• Loss of consciousness.

• Generalized tonic – clonic seizure.

Page 40: Medical Emergencies · CONTENTS • Introduction • Objectives • Prevention of medical emergency • Preparation for emergencies • Recommended dental office emergency drugs •

Treatment-

• Usually self limiting , convulsions lasting 2-5 minutes.

• Place patient in supine position.

• Primary aim is to prevent injury.

• Remove all materials and instruments from mouth & vicinity.

• Gently restrain patient.

• Maintain PABC on recovery .

• If convulsion last for more than 5 minutes or reappear at short

intervals, dial EMS.

• In the meantime administer diazepam 0.3 mg/kg, IV if

trained.

Page 41: Medical Emergencies · CONTENTS • Introduction • Objectives • Prevention of medical emergency • Preparation for emergencies • Recommended dental office emergency drugs •

CONCLUSION

• Many medical emergencies can be treated without drugs.

Without ABCDs of CPR, drugs are of little value.

• All office personal should be trained to assist in the

recognition and management of emergencies, which

includes biannual renewal of BLS skills.

• The office staff should have pre-assigned specific

responsibilities so that in the event of an emergency each

person knows how to manage.

Page 42: Medical Emergencies · CONTENTS • Introduction • Objectives • Prevention of medical emergency • Preparation for emergencies • Recommended dental office emergency drugs •

REFERENCES

• Marwah N, Nonpharmacological Behaviour Management, Textbook

of Pediatric Dentistry,3rd ed. Jaypee;2014; 219.

• Casamassimo et.al. Pain reaction control : sedation, Pediatric

Dentistry Infancy through Adolescence, 5th ed. Elsevier; 2013; 110

• Malamed SF. Emergency Medicine in Pediatric Dentistry: Preparation

and Management. C.D.A. journal. 2003; 31.

• Vranić DN et al. Medical Emergencies in Pediatric Dentistry. Acta

stomatol Croat. 2016;50(1):72-80 .

• Basic Life Support/ Cardiopulmonary Resuscitation. American

Academy Of Pediatric Dentistry, 2015.

• Management of Medical Emergencies. American Academy Of

Pediatric Dentistry , 2015 ; 37.