Medical Emergencies - FINAL

7/29/2019 Medical Emergencies - FINAL

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MedicalEmergencies


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Basic Principles of

Medical EmergencyManagement

PREVENTION is the mostimportant phase of treatingmedical emergencies, however

despite all efforts at prevention,EMERGENCIES will likely tohappen.


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THREE STEPS TO PREVENTMEDICAL EMERGENCIES IN THE

DENTAL CLINIC:

1. MEDICAL HISTORYA. Are there any recent changes to health?

B. Is the px under the care of a physician?C. Has the px had any serious illness/

operation?

D. Is the px taking any drugs/medications?E. Does the px have any allergies?F. Is the px pregnant?


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G. For already diagnosed disorders mustask:1. When did the px develop the disease?2. How is the problem controlled?3. Is there anything that makes theproblem worse?4. Has the px been hospitalized for the

problem?5. Are there any restrictions on the px?


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2. PX EVALUATION

A. Record vital signsB. Complete dental examC. Visual inspection of px

Formulate your tx plan at this stage.Determine how this tx plan relates to or

is affected by the findings of the medicalhistory & evaluation. Obtain medicalconsults if needed at this point.


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3. STAFF TRAINING ANDPREPARATION

A. Training: Staff needs to haveknowledge to identify and

correctly manage eachemergencyB. Easily accessible emergency

equipment and drugsC. Coordination of office

personnel


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What is adequate preparation?

Guidelines vary, but in general, it isexpected that the dentist will beable to initiate emergency mgt. andbe capable of sustaining a victimslife through the application of BasicLife Support (BLS).

***In times of crisis, simplicity haltsconfusion.***


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BASIC PRINCIPLE OF MANAGINGALL MEDICAL EMERGENCIES

1. BLS: remember ABCs 2. Place the px supine3. Call for assistance4. Assure px if conscious5. Maintain airway6. Place px on oxygen as indicated by

nature of emergency7. Monitor vital signs8. Diagnose nature of event9. Initiate specific tx10. Document, document, document!


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STRESS REDUCTION PROTOCOLFOR THE ANXIOUS PX

1. Recognize pxs anxiety level 2. Consider using pre-medication/

sedation

3. Schedule morning appointments4. Minimize waiting time and watchappointment length

5. Make sure to use adequate paincontrol. (varies from px to px)6. Monitor vital signs

7. Medical consultation if required


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Airway ObstructionGeneral signs and symptoms

1. Gasping of breath2. Px grabs at throat3. Panic4. Suprasternal/supraclavicular

retraction

If Partial Obstruction - snoring,gurgling, wheezing, growling

If Total Obstruction - no noise


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Causes of Airway Obstruction1. Hypo-pharyngeal obstruction

(foreign bodies)

2. Blood, water, or saliva inmouth3. Bronchoconstriction4. Laryngospasm5. Tongue (most common)


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Treatment 1. Place px supine on the floor/ 15-30 0 back

in the dental chair 2. Head tilt/chin lift3. Check airway & breathing, assess cause

of obstruction

4. If cause by fluid use suction5. Consider jaw thrust6. Reassess airway and breathing

7. If not breathing attempt CPR8. Reassess airway and breathing9. If cause by foreign body use HEIMLICH

MANEUVER


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HEIMLICHMANEUVER/

ABDOMINAL THRUST/ABDOMINAL HUG


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ON ADULT


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ON A CHILD


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ON INFANT


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ON ONESELF


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CARDIOPULMONARYRESCUCITATION


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Remember the CAB of CPR

Circulation : Restore bloodcirculation with chest

compressionsAirway : Clear the airway

Breathing : Breathe for theperson


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Airway: Clear the airway -Open the person's

airway using thehead-tilt, chin-liftmaneuver. Putyour palm on theperson's foreheadand gently tilt thehead back. Thenwith the other hand, gently liftthe chin forwardto open the

airway.


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Breathing: Breathe for the person


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Rescue breathing can be mouth-to-

mouth breathing or mouth-to-nosebreathing if the mouth is seriouslyinjured or can't be opened.

With the airway open (using thehead-tilt, chin-lift maneuver), pinchthe nostrils shut for mouth-to-mouth breathing and cover theperson's mouth with yours, makinga seal.

Ci l i R bl d


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Circulation: Restore bloodcirculation with chest compressions


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Put the person on his or her back

on a firm surface.Kneel next to the person's neck andshoulders.Place the heel of one hand over thecenter of the person's chest,between the nipples. Place your other hand on top of the first hand.

Keep your elbows straight andposition your shoulders directlyabove your hands.


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Use your upper body weight (not just your arms) as you push

straight down on (compress) thechest at least 2 inches(approximately 5 cms). Push hardat a rate of about 100 compressionsa minute.If you haven't been trained in CPR,continue chest compressions until

there are signs of movement or until emergency medical personneltake over. If you have been trainedin CPR, go on to checking the

airway and rescue breathing.


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Hyperventilation

Signs and symptoms:1. dizziness2. hard to breathe3. shaking and trembling4. cold clammy hands5. tight feeling in chest, chest pain and

palpitations

6. lightheaded7. uncontrolled over breathing 25-30/min.8. increase BP and heart rate9. tingling in hands, feet and perioral areas


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Management of Hyperventilation

1. Discontinue tx and remove anyforeign objects from the pxs mouth 2. Position px upright3. Assess airway4. Reassure px and try to calm them5. Have px breath slowly and

shallowly into a paper bag or mask6-10x/min.

6.Monitor vital signs7. Determine what precipitated attack8. Dismiss px only after vitals signs

returned to normal


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Allergic Reaction

Signs and symptoms1. cutaneous rxns. urticaria,

itching2. angioedema (swelling)3. tightness in chest, sneezing4. ocular rxns. conjunctivitis,

watery-eyes

5. hypotension


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ANAPHYLAXIS severe systemic typeof allergic reaction and is a medicalemergency

Signs and symptoms:1. cardiovascular shock including pallor,

syncope, palpitations, tachycardia,hypotension, arrythmias, andconvulsions

2. respiratory symptoms include sneezing,cough, wheezing, chest tightness,

bronchospasm, laryngospasm3. skin is warm and flushed with itching,urticaria, angioedema

4. nausea, vomitting, abdominal cramps,and diarrhea also possible


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Treatment:General tx: ABCs, maintain airway,

administer oxygen, monitor vital signs,and if in shock, put px in a horizontalposition or slight Trendelenburg position(head lower than leg position)

Mild Reaction: antihistamines usuallyeffective (Benadryl 50-100mg/Cholpheniramine maleate 4-12mg PO, IVor IM), identify and remove allergen,

follow up medication every 4-6hrs.Severe Reaction: call emergency hotlineand bring the px to the nearest hospitaland observe within 24 hrs.


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Asthma Attack Signs and Symptoms:

1. suffocation2. chest pressure/tightness3. non-productive cough4. wheezes5. expiration is prolonged than

inspiration6. chest is distended7. thick stringy mucous


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Severe asthma attack includes: cyanosis of the nail beds,perspiration and flushing of theskin, px may appear confused and

agitated, use of accessory musclefor respiration (sternocleido-mastoid and shoulder/ abdominalmuscles)


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Management of an AsthmaAttack

1. discontinue dental tx2. place px in easiest position for them tobreath (usually upright with armsoutstretched)

3. Albuterol inhaler (Proventil) 2 puffsevery 2 mins.4. supplemental oxygen at 10L/min. if

available

5. monitor vital signs6. if no improvement, call emergency7. start IV, epinephrine 1:1000 -

0.3g/20mins. If available

l d f h


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Dental Tx Consideration for theAsthma Px

1. take a good medical historyprior to tx determine how oftenthe attack and what precipitates

it2. schedule morning appointments3. if px uses inhaler they should

bring it on hand during tx(consider prophylactic use prior to tx)


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Angina PectorisSigns and symptoms:

1. substernal pain from chest andradiates to any area above thediaphragm

2. vary form heavy squeezing pain to aheavy pressure on the chest

3. pain usually lasts for few mins. and

disappears with rest4. other symptoms: palpitations, faintness,

dizziness, dyspnea, digestivedisturbance


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Management of Angina Pectoris1. stop all tx2. position px upright3. call emergency4. administer oxygen if available

5. monitor and record vital signs6. administer one tablet of Nitroglycerin

sublingually7. if no relief after two mins. Repeat

Nitroglycerin (can repeat a third time if no relief but if after the 3 rd time still norelief, the px may be suffering from heartattack))


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Dental Consideration for Px withAngina history

1. tx should be oriented towardsprevention of angina attack

2. pre-medication of Nitroglycerinsublingually prior to any injectionor surgical procedures

3. administer oxygen by nasal canuladuring procedure

4. consider use of oral/IV sedation toreduce anxiety


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Heart Attack (Myocardial Infarction)

Signs and symptoms:1. preceded by angina2. heavy, squeezing, pressing or crushing

pain in nature (pain located over middle3 rd of sternum)

3. pain radiates to left arm in many casesand can also radiate to the mandible

4. not relieved by Nitroglycerin5. px express intense fear, restless6. dyspnea (shortness of breath)7. Levines sign: px clutch chest with fist


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Management of Heart Attack1. stop all tx2. clear mouth with any foreign

objects3. place px in an upright position

4. if available administer oxygen 10L-15L/min.5. call emergency, send px to hospital6. monitor and record vital signs7. give px Aspirin (325mg.) if

available8. if px loses consciousness, initiate

BLS

S


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Syncope(Fainting/Unconsciousness)

Signs and symptoms can be divided into3 categories:

1. Pre-syncope: warm feeling in face/neck,pale, sweating, feels cold, abdominaldiscomfort, dizziness, dilated pupil,yawning, fast heart rate, slight decreasein BP

2. Syncope: fainting, generalized musclerelaxation, weak pulse, twitching of hands/legs/face, eyes open

3. Post-syncope: heart rate increases, BPback to normal, mental confusion


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Management of Syncope1. stop all tx2. remove all objects inside pxs

mouth3. place px in supine position

with legs elevated and head atlevel of heart

3. establish ABC4. use Ammonia5. if unconscious for more than 1

min., call emergency


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TYPES1. Hemorrhagic loss of blood2. Respiratory insufficient breathing

3. Neurogenic interference with thesympathetic nervous

system

Shock


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4. Psychogenic thoughtpatterns in the brain

5. Cardiogenic

inadequate function of the heart

6. Septic cause bybacterial, microbial, or viral infection


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7. Anaphylactic allergicreaction (antigen-antibody rxn)

8. Metabolic diabetes,low blood sugar, insulinshock

9. Postural suddenchange of body position


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Management of Hemorrhagic ShockMechanical means1. Application of folded, sterile

gauze square compressedover the wound for 20-30min.

2. Suturing3. Electric cautery

4. Ligation of vessel


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COMMONLY USEDHEMOSTATIC DRUGS INDENTISTRY1. Monsels solution

2. Thrombin3. Tannic acid

4. Gel foam5. Oxygel6. Surgicel


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HEMOSTATIC DRUGS

1. COAGULANT - promotesblood clotting

2. ASTRINGENT - appliedtopically causing capillariesto contract

3. EPINEPHRINE - controlsminor bleeding


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Management of PosturalShock

1. Immediately reposition the px ina supine position

2. If the px is unconscious and

does not revive,tilt his head back(chin up) and check hisbreathing. If not normal, do tripleairway check

3. Slowly return the px in an uprightposition. If he feels dizzy andfaint, lower him to the supine

position at once.

f


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Management of Anaphylactic Shock 1. Anti-histamine2. Epinephrine 1:1000 in a dosage

of .5 ml subcutaneously in thearm or thigh. If severe,additional dose after 10

minutes3. Oxygen to relieve patients

distress along with anti

histamine


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Management of

Cardiogenic Shock1. Let px sit upright at a 45

degree angle2. Give oxygen and call

emergency


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Management of

Psychogenic Shock1. Lower the px to a supine

position.2. Pxs feet should be elevated

to a position higher than hishead to cause the blood toflow towards the brain(Trendelenberg position)


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3. An ampoule of spirits of ammonia may be fractured ina gauze square and waftedgently under the patientsnostrils.

4. The PR and the BP should betaken and recorded for thedentist to interpret. Usuallypx regains consciousnesswithin 1 to 2 minutes.


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EpilepsyClassification:

1. Petit mal-mild and brief in duration,few seconds

-px may seem to be staringinto space


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2. Grand mal-severe with loss of consciousness, followedby violent contraction of the muscles

-may last several minutes


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Management of Epilepsy

1. Protect the px from self injury

2. Heavily padded tonguedepressor or folded towelshould be placed betweenthe pxs teeth to preventtongue biting


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3. Attempt to maintain afree airway for the px but

do not put your fingersin the pxs mouth


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NOTE:

OVERFATIGUE ANDANXIETY TRIGGERS

SEIZURE - Epileptic pxs should

be scheduled for txearly in the day


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STROKE

also known as a cerebrovascularaccident (CVA)It is the rapid loss of brain functiondue to disturbance in the bloodsupply to the brain.This can be due to ischemia (lack of blood flow) caused by blockage(thrombosis, arterial embolism), ora hemorrhage (leakage of blood


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Signs and symptoms

Smoothing out of foreheadEyebrow droopDrooping of the corner of themouth


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Classification of stroke1. Ischemic - occur as a result of an

obstruction within a blood vesselsupplying blood to the brain. Theunderlying condition for this type of

obstruction is the development of fatty deposits lining the vessel walls.2. Hemorrhagic - It results from a

weakened vessel that ruptures andbleeds into the surrounding brain.The blood accumulates andcompresses the surrounding brain

tissue.


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Risk factors of stroke Over age 55 More common in males

African American,Hispanic or Asian/PacificIslander

A family history of stroke High blood pressure

Hi h h l t l


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High cholesterol Smoking cigarettes

Diabetes Obesity and overweight Cardiovascular disease A previous stroke or transient

ischemic attack (TIA) High levels of homocysteine (an

amino acid in blood)

Birth control use or other hormonetherapy Cocaine use Heavy use of alcohol

DENTAL MANAGEMENT OF THE


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DENTAL MANAGEMENT OF THESTROKE PATIENT

A patient with stroke in his record shall getspecial care during dental treatment:appointments shall be for choice in the

morning, shall be short and without stress.Clinical approach shall take intoconsideration in several aspects: Disabled patients shall be helped by the nurse to

sit on dental chair, their airways shall be free andthey shall be accompanied by the persons takingcare of them, especially if speech difficulties arepresent



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Anamnesis shall be simple and optimistic, dentistshall stand in front of the patient, without mask,shall look him in the eyes, shall move slowly andquestions shall be simple and clear, for plainanswers (yes/no)

Anamnesis should reveal patients risk factors: if themedical record shows high blood pressure, cardiacdiseases, transient vascular accidents, diabetes,heavy smoking, old age, then such a patient isprone to stroke and/or myocardial infarction.

History of past strokes needs to be elicited: date,seriousness, treatment, disabilities. There aresituations when patients speech is not affected, buthe cannot realize the extent of the palsy (he is notaware of it) or situations when a patient with braininjury on his right side is neglecting his left side of

the body



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Blood pressure and pain should bemonitored and under control duringthe entire intervention

Emergency dental treatment isallowed six months after stroke, itshould be performed carefully, byneurologists advice and someprecautions are needed, according tothe specific characters of the stroke



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STROKE PATIENT If needed, dental treatment produces

bleeding (teeth extraction, pulpectomy,subgingival scaling, periodontal surgery),anticoagulant systemic medication maycause serious hemorrhage, thereforeanticoagulant drugs like heparin should bestopped at least 6-12 hours beforetreatment. Six hours after bleeding, whenblood clots are built up, heparin systemictreatment can be resumed. If there is some

other anticoagulant medication involved,it should be stopped several hours or daysbefore bleeding dental treatment, afterdetermining the International ClottingRate (ICR) and decision depends onneurologists advice


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The dentist should be ready foremergency intervention in case of local hemorrhage, with haemostatic

medication and cautery, bloodpressure should be monitored andoxygen therapy device is needed in

dental office



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The minimal amount of anestheticsolutions should be injected,concentration of added epinephrineshould be very low (1:100.000 or1:200.000). Use of gingival retractioncord soaked with epinephrine shouldbe avoided.Metronidazolum and tetracyclineshould be avoided, since they mayaffect blood clotting.If the patient shows symptoms of stroke, he should get oxygen therapyimmediately and should be referred toa hospital as soon as possible.



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If patients show minor physicaldisabilities after stroke, they canpresent poor oral hygiene. For suchpatients, dentists will advise the useof electric toothbrushes, easier tohandle, use of dental floss, oralirrigation and prophylaxis usingchlorhexydine and fluoride.


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Patients with speech and deglutitiondisabilities due to paralysis of oro-facial

muscles, with loss of sensitivity of thetissues, with flaccid, multiple pleated andpossibly asymmetrically positionedtongue, with dysphagia, may presentaccumulation of food residues on teeth,tongue, oral mucosa. They must learn toclean their teeth and oral cavity usingonly one hand or to get/accept anotherpersons help, in order to avoid caries,periodontitis, halitosis or oral mucosadiseases.



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Edentulous patients are advised toget fixed prosthodontic treatment,because of the difficulties of insertion and removal of removabledentures.

Medical Emergencies - FINAL

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