Medical emergencies in dental practice

GOOD MORNING

Management of medical emergencies in dental

office

Presented by: Dr. MANU MATHEW

INTRODUCTION

• They do happen in dental office• Can be – patient

Doctor Staff By stander

• McCarthy- all but 10% can be prevented

CLASSIFICATION

• Systems oriented -infectious -respiratory system

-cardiovascular system -nervous system -git and liver

• Cardio vascular and non cardio vascular - stress related

- non stress related• Based on clinical signs and symptoms -unconciousness

-respiratory distress -altered conciousness -seizures -drug related emergencies -chest pain -sudden cardiac arrest

PREVENTION• Goldberger – when you prepare for an

emergency, the emergency ceases to exist• Physical evaluation -physically

-psychologically -treatment modifications -psychosedation- appropriate technique &drug

PHYSICAL EVALUATION

• Medical History• Physical Examination• Vital Signs• Dialogue History• Anxiety recognition• Determination of Medical Risk

MEDICAL HISTORY

• Questionnaire divided into-signs &symptoms-diagnosed diseases-medical treatments

• Update• Medication• Medical consultation

PHYSICAL EXAMINATION

• Visual inspection of patients• Auscultation,monitoring & lab tests • Referral to physician• Monitoring Vital signs

VITAL SIGNS

• Blood pressure• Pulse rate• Respiratory rate• Temperature• Height• Weight

DIALOGUE HISTORY

• Check accuracy of medical history• Recognize anxiety

ANXIETY RECOGNITION

• Medical history questionnaire• Dental anxiety questionnaire- Dr.Norman

Corah• Observation

-excessive bp and heart rate-trembling-excessive sweating-dilated pupils

DETERMINATION OF MEDICAL RISK

• Ability of patient to safely tolerate dental treatment.

• Does patient represent increased medical risk?

• Can patient be managed in the dental office?

ASA PHYSICAL STATUS CLASSIFICATION SYSTEM

• American society of anaesthetologists• 1962• 5 categories

ASA I

• A patient without systemic disease• A normal healthy patient• Can tolerate stress involved in dental

treatment• No added risk of serious complications• Treatment modification usually not

necessary

ASA II

A patient with mild systemic disease like-Well-controlled diabetic-Well-controlled asthma-ASA I with anxiety• Represent minimal risk during dental treatment• Routine dental treatment with minor

modifications-Short early appointments-Antibiotic prophylaxis

ASA III

A patient with severe systemic disease that limits activity but is not incapacitating like - a stable angina, 6 mos. Post – MI,6 mos. Post – CVA, COPD• Elective Dental Treatment is not contraindicated• Treatment Modification is Required

- Reduce Stress- Sedation- Short Appointments

ASA IV

• A patient with incapacitating systemic disease that is a constant threat to life like unstable angina pectoris, MI&CVA(within 6 mos.),BP>200mmHg or 115mmHg

• Elective dental care should be postponed• Emergency dental care only

–Rx only to control pain and infection–When immediate intervention is needed

should be done in a hospital

ASA V

• A moribund patient not expected to survive more than 24 hrs with or without surgery

• They may be referred to as DNAR (Do Not Attempt Resuscitation) or no code patients

• It includes end stage of renal diseases, cancer,hepatic disease

• ASA E• Emergency operation of any variety, withE

preceding the number to indicate the patient’s physical status like ASA E- III

• ASA VI -recently added• Defined as a declared brain-dead patient

whose organs are being removed for donor purposes

STRESS REDUCTION PROTOCOL

• Recognition of medical risk & anxiety• Medical consultation• Premedication – 1 hr prior to procedure• Appointment scheduling• Minimized waiting time• Vital signs- pre & post op• Psycho sedation during treatment

• Adequate pain control during the treatment• Duration of dental treatment• Post operative control of pain and anxiety

PREPARATION

• Team Effort• BLS for all office personnel• Emergency drills• Emergency phone numbers • Emergency equipment

EMERGENCY DRUG KITSCRITICAL DRUGS• Adrenaline (Epinephrine)

1 in 1000• Antihistamines• Oxygen• Aspirin• Anti hypoglycemic- sugar• Vasodilator (GTN

tabs/sprays)• Bronchodilator

(Salbutamol inhaler)

ABC OF EMERGENCY

• A- AIRWAY• B- BREATHING• C- CIRCULATION

AIRWAY

• Finger sweep• Suction• Head tilt/Chin lift

BREATHING

• Look- listen- and- feeltechnique

CIRCULATION

• Monitoring the BP and heart rate• In non emergency situations -brachial

-radial• In emergency

- Carotid artery in the neck

CPR

• 30 chest compressions to 2 ventillations in adult

• For chest compression- patient should lay on a flat firm surface

- skin must be visible - place heel of one hand over centre of

victim’s chest - put the heel of other hand on top of first

-straighten your arms and position your shoulders directly over the hands

- push hard and fast upto 1.5 to 2 inches with each compression

- at the end of each compression allow chest to recoil or re expand

- compress at a rate of 100 per minute

SYNCOPE

• Most commonly observed emergency in dental office-50% by Malamed and Fast et al

• Transient loss of conciousness• Decreased cerebral perfusion• Critical level of blood flow- 30mL of blood

per 100g of brain tissue per minute

SYNCOPE

Syncope-clinical features

Early• Nausea• Warmth• Perspiration• loss of color• Baseline Blood press• Tachycardia

Late• Hypotension• Bradycardia• Hyperpnea• Pupillary dilation• Peripheral coldness• Visual disturbance• Loss of

consciousness

Syncope- Management

1. Assessment of unconciousness- shake and shout

2. ABC3. Definitive care

-administration of O2

-monitoring vitals -additional procedures

POSTURAL HYPOTENSION

• 2ND leading cause• Drop in systolic BP of 30mmHg or

10mmHg drop in diastolic BP

Predisposing factors

1. Administration and ingestion of drugs- vasodilators, α blocker, β blocker

2. Prolonged recumbency and convalescence3. Inadequate postural reflex4. Pregnancy- supine hypotensive syndrome of

pregnancy5. Venous defects in legs6. Chronic postural hypotension(shy-drager

syndrome)7. Physical exhaustion and starvation

Management

• Same as syncope• ABC• Changes in posture should be done slowly

RESPIRATORY DISTRESS

• OBSTRUCTED AIRWAY• HYPERVENTILATION• ASTHMA

OBSTRUCTED AIRWAY

• Foreign body aspiration• Laryngeal edema

PREVENTION

• Rubber dam• Oral packing- pharyngeal curtain• Chair position• Suction• Magill intubation forceps• Ligature- dental floss

Management

• 1 Recognize un conciousness• 2 Call for help • 3 Position victim (supine) • 4 head tilt • 5 Assess airway and breathing • 6 Attempt to ventilate • 7 Reposition head (head tilt) and attempt to

ventilate • 8 Jaw thrust maneuver

Management –contd.

• 9 Attempt to ventilate • 10 Activate EMS system • 11 Deliver 6 to 10 abdominal thrusts • 12 Check mouth for foreign body • 13 Attempt to ventilate • 14 Repeat steps 11 to 13 until successful • 15 Cricothyrotomy

Cricothyrotomy

HYPERVENTILATION

• Ventilation in excess of that required to maintain normal blood PaO2 and PCO2

• Increase in depth or frequency• Almost always a result of extreme anxiety

Clinical features

• Palpitations • Tachycardia • Dizziness• Numbness or tingling of extremities• Dryness of mouth• Shortness of breath• Tremor

Management

• Termination of dental procedure• ABC• Removal of materials from mouth• Calming the patient- reassurance• Drug management if necessary

ASTHMA

• Chronic inflammatory disorder characterised by reversible obstruction of the airways

• 2 categories- extrinsic(allergic)- intrinsic(non allergic/idiopathic)

• Status asthmaticus- most severe clinical form-wheezing, dyspnoea,hypoxia

Management

• Termination of dental therapy• ABC• Administration of O2 • Administration of bronchodilators like

albuterol• In sevete cases call for assisstance

DRUG OVERDOSE REACTIONS

• Can be due to- local anaesthetics- antibiotics-analgesics

Local anaesthetic overdose reaction

• SIGNS• Low to moderate

-confusion- talkativeness- excitedness- slurred speech- elevated BP, heart rate, resp. rate

• Moderate to high- generalised tonic clonic seizure- CNS depression- depressed BP, heart rate, resp. rate

• SYMPTOMS-Headache-dizziness-blurred vision-drowsiness-disorientation

Management

• Termination of procedure• ABC• Administration of O2 • Administration of anti convulsant if needed• Medical assisstance

ALLERGY

• A hypersensitive state acquired through exposure to a particular allergen, re-exposure to which produces heightened capacity to react

Gell & Coombs Classification

• Type 1 ( IgE – Mediated Hypersensitivity)-most life threatening-few minutes• Type 2 ( Cytotoxic / Cytolytic antibody

mediated) -IgM or IgG antibodies mediate• Type 3 ( Immnune complex mediated )-1- 4 weeks, IgM – IgG soluble metabolite• Type 4 (delayed Hypersensitivity )-sensitized T cell lymphocytes

Anaphylaxis

• SIGNS AND SYMPTOMS• Paraesthesia, flushing, facial swelling• Generalised itching – hands and feet• Bronchospasm and laryngospasm

(wheezing and breathing difficulty)• Rapid weak pulse together with fall in

blood pressure

Management

• ADRENALINE (Epinephrine)• Immediate administration of IM

epinephrine 1:1000 in a dose of 0.3mL(0.3 mg adult)

• Administered every 5 to 20 minutes• If IV route available administer 1 mL of

1:10000(0.1mg) by slow IV push over 3-5 minutes

SEIZURES

• Manifestation of brain dysfunction• Excessive neuronal cortical discharge• Secondary to toxins, drugs, cerebral

hypoxia, or metabolic disturbances

Causes

• Congenital abnormalities• Perinatal injuries• Metabolic and toxic disorders• Head trauma• Tumors • Vascular diseases• Infectious diseases

Management

• Termination of procedure• ABC• Prevention of injury• Monitoring vitals• Reassurance • Medication should only be given if

convulsive seizures are prolonged or last 5 minutes or more or are repeated rapidly

• Usually used drug is a benzodiasepine either diazepam-5-10mg via IV route at a rate of 5mg per minute and repeated every 10-15 minutes to a max. Dose of 30mg or midazolam 10 mg

HYPOGLYCEMIA

• Inadequate food intake• Excessive insulin dose• Oral hypoglycemic therapy• Strenuous exercise• Alcohol intake• Kidney failure, liver failure

Clinical features

• EARLY STAGE-diminished cerebral function- changes in mood - hunger- nausea

• MORE SEVERE STAGE-sweating-tachycardia

-piloerection- increased anxiety- poor judgement- un cooperativeness

• LATER SEVERE STAGE-un conciousness- seizures- hypotension-hypothermia

Management

• Termination of procedure• ABC• Summoning medical assisstance• Administration of carbohydrates

-IV injection of 50%Dextrose solution-glucagon IM- epinephrine IM

ADRENAL INSUFFICIENCY

• Deficiency of adrenal hormones- ADDISONS disease-primary

exogenous corticosteroid therapy-secondary

• Signs and symptoms – Loss of consciousness– Rapid, weak or impalpable pulse– Blood pressure falls rapidly

Management

• Termination of procedure• ABC• Recognition of unconciousness• Administration of glucocorticosteroids

- 100mg hydrocortisone IM or IV

Chest pain

• Angina pectoris- most common• Hyperventilation• Myocardial infarction

ANGINA PECTORIS

• Dr. William Heberden in 1768• A characteristic thoracic pain, usually

substernal; precipitated chiefly by exercise, emotion or heavy metal; relieved by vasodilator drugs and few minutes rest

Management

• Terminate procedure• ABC• oxygen• Position patient comfort• Vitals • Emergency Medical Service • Vasodilators-Nitroglycerin : spray or tab 0.4mg

repeat three times every 5 min not more than 3 doses

MYOCARDIAL INFARCTION

• Caused by deficient coronary arterial blood supply to a region of myocardium resulting in cellular death and necrosis

• Main cause is atherosclerosis

Clinical features

• SYMPTOMS- pain- severe to intolerable, prolonged(30 min)- nausea and vomiting- weakness- dizziness- palpitations-cold perspirations- sense of impending doom

• SIGNS- restlessness- acute distress- skin- cool, pale, moist- heart rate- bradycardia to tachycardia

Management • Termination of procedure• Diagnosis • ABC• Administer oxygen• Summon medical assistance• Administer nitroglycerin• Antiplatelet therapy• Monitoring vitals• Shifting to hospital

TRIGEMINO-CARDIAC REFLEX

• First described in 1999 by B J Schaller et al

• phenomenon consisting of bradycardia, arterial hypotension, apnea, and gastric hypermotility

• The sensory nerve endings of the trigeminal nerve send neuronal signals via the Gasserian ganglion to the sensory nucleus of the trigeminal nerve, forming the afferent pathway of the reflex arc.

• This afferent pathway continues along the short internuncial nerve fibers in the reticular formatio to connect with the efferent pathway in the motor nucleus of the vagus nerve.

• Koerbel et al found that the manifestations became normal once the stimulus was removed

CONCLUSIONS

• Emergencies will occur• The use of emergency drugs is safe –

when the diagnosis is correct• The drug kit should be checked regularly

to ensure that it is up to date

BIBLIOGRAPHY

• Handbook of Medical Emergencies in the Dental Office, Stanley F. Malamed

• Medical Emergencies in Dentistry, Jeffrey D. Bennett , Morton B.Rosenberg

• Trigeminocardiac reflex during skull base surgery: mechanism and management

A.Koerbel,A.Samii• Trigemino-cardiac reflex in humans initiated by

peripheral stimulation during neurosurgical skull-base operations. Its first description J.Schaller

THANK YOU

Medical emergencies in dental practice

Health & Medicine

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