MEDICAL EMERGENCIES IN

DENTISTRY

Presented By :- Chetan Barai v.s.p.m. dental college nagpur

INTRODUCTION

INCIDENCE

TYPES OF EMERGENCIES• PREVENTION• PREPARATION• MANAGEMENT

SUMMARY

CONCLUSION

REFERENCES

CONTENTS

INTRODUCTION

In spite of the most meticulous protocols designed to prevent

the development of life threatening situations, emergencies

still occur.

Such emergencies can occur in any environment, we as

“Dental Surgeons” should be always alert and should have a

thorough understanding about different emergency situation

which may come across during ones practice.

Incidence A survey done in the 90’s showed that, over a 10 year

period, 90% of dentists have encountered at least one medical emergencies.

TYPE OF EMERGENCYTYPE OF EMERGENCY NUMBERNUMBER PERCENTPERCENT

Altered Altered ConsciousnessConsciousness

17,78217,782 5959

CardiovascularCardiovascular 4,2804,280 1414

AllergyAllergy 2,8872,887 9.59.5

RespiratoryRespiratory 2,7182,718 99

SeizuresSeizures 1,5951,595 55

Diabetes-RelatedDiabetes-Related 999999 33

PREVENTION: Physical Evaluation

• Medical history questionnaire

• Physical examination (vital signs, visual

inspection, auscultation of heart and lungs)

• Dialogue history (recognition of anxiety)  

Medical history questionnaire:

• Thorough questionnaire

• Past medical history

• Familial disease history

• Diet

Anxiety

Observation

• Increased BP & Heart rate

• Excessive sweating

• Dilated pupils

Psychological examination

Classification based clinical signs and symptoms: Unconsciousness

Vasodepressor syncope

Orthostatic hypotension

Respiratory difficulty

Airway obstruction

Hyperventilation

Asthma

Heart failure and acute pulmonary edema

Altered consciousness

Hyperglycemia and hypoglycemia

Hyperthyroidism and hypothyroidism

Cerebrovascular emergencies

Seizure disorders

Drug related emergency situations

Drug overdose reactions

Allergy

Chest painAngina pectoris

Acute myocardial infarction.

DETERMINATION OF MEDICAL RISK

Physical status classification system (1962, American

Society of Anesthesiologists)

ASA I : A patient without systemic disease, a normal

healthy patient

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 VI : Clinically dead patient being maintained for

harvesting organs.

ASA E : Emergency operation of any variety; E precedes the

number, indicating the patients physical status

( ASA E-III)

Unconsciousness :

Possible causes of unconsciousness Vasodepressor syncope Drug administration Orthostatic hypotension Epilepsy Hypoglycemic reaction Acute adrenaline insufficiency Acute allergic reaction Acute MI Hyperglycemic reaction Hyperventilation

Prevention Via prevention of predsposing factorsUse of psychosedative drugs

• Ingestion - Alprazolam (4mg), Diazepam (5mg)

• I.M / I.V administration – Butorphenol (1mg), Midazolam (5mg)

• Inhalation - N2O(15%) + O2(85%)

VASODEPRESSOR SYNCOPE

Most common form of emergency medical situation in

Dental office.

The terms syncope and faint commonly are used

interchangeably to describe transient loss of

consciousness caused by reversible disturbances

in cerebral function.

PREDISPOSING FACTORSPSYCHOGENIC NON PSYCHOGENIC Fright Anxiety Emotional Pain (sudden) Sight of blood, syringe etc

Erect sitting or standing posture

Missed meal (hunger) Exhaustion Poor physical condition Hot humid environment

Critical level of cerebral blood flow for maintenance of consciousness is estimated to be about 30ml/100gm/min.

normal cerebral blood flow is 50 – 55 ml/100 gm/min.

Systolic BP may descend to as low as 20 -40 mmHg

Seizures may be precipitated depending upon the brain damage.

SYNCOPE

PATHOPHYSIOLOGY

CLINICAL FEATURESPRE SYNCOPE

Feeling of warmth in neck and face

Colour changes to pale to ashen grey

Pupillary dilatation

Yawning

Cold extremities

Hypotension

Bradycardia

Loss of consciousness

Pulse becomes weak, thready, irregular.

Respiration becomes irregular, jerky, shallow, or may

entirely cease

Death like appearance of the patient

SYNCOPE

POST SYNCOPE Pallor

Nausea

Weakness

Sweating

Management Terminate all dental treatment

Supine position with legs raised

Attempt to calm the patient

Monitor vital signs

Assessment of consciousness (“shake and shout”)

Check for breathing

Positioning the patient

Ammonia Vapour

stimulationPharmacological managemnt:

25% dextroseHydrocortisoneAtropine

SHOCK

Type of shocks

1. Hypovolaemic shock

2. Cardiogenic shock

3. Septic shock

4. Anaphylactic shock

5. Neurogenic shock

A critical condition that is brought on by a sudden drop in blood flow through the body.

Shock is a major medical emergency which is common after serious injury.

Haemorrhage, severe vomiting and Diarrhoea.

Acute Myocardial infarction

Gram-positive and gram-negative bacterial infection, other organisms.

Drugs, insect stings

High cervical cord injury, severe Head injury.

Causes

Management ABC including high flow oxygen

Position patient in Trendelenburg position

Identify underlying cause

Establish haemostatis

Administration of intravascular fluids

Monitor vitals signs

Improving systemic perfusion and oxygenation

Anaphylaxis

Clinical features

Wheezing

Abdominal pain

Nausea

Urticaria

Flushing of face

It is a serious allergic reaction that is rapid in onset and may cause death.

Par aesthesia

Pallor

Rapid and weak pulse

Cyanosis

Edema of face

Management Terminate dental treatment

Maintenance of IV line

Supine position legs elevated

0.2-0.5ml of 1:1000 epinephrine IM

Followed by chlorpheniramine 10mg IV

Hydrocortisone 20mg IV

Monitor vital signs

POSTURALHYPOTENSION

Decline >20 -25 mm Hg in SBP or

a decline >10 mm Hg in DBP.

HR baseline or > 30 bpm

When moves from a supine to a

sitting or standing position

PREDISPOSING FACTORS

Ingestion of drugs

Prolonged period of recumbency

Inadequate postural reflex

Late stage pregnancy

Venous defects in the legs

Physical exhaustion and starvation

CLINICAL FEATURES Asymptomatic, BP changes without symptoms.

Symptomatic, such as dizziness and faintness

occur with BP changes.

Acute or reversible , typically caused by volume

loss or medication use.

Chronic or irreversible , caused by endocrine and

neurogenic factors. 

MANAGEMENT –Positioning The unresponsive patient should be placed

into the supine position with the feet slightly elevated this position immediately enhances cerebral perfusion, and in most instances individual regains consciousness within a few seconds.

Prevalence of OH with labetalol is 1.4%.

Enalapril (5-20 mg/d) reduces OH episodes,

whereas long-acting nifedipine (30-90 mg/d)

increases episodes.

Affects ~50 million people in the US Types:

1. Primary:- Chronic high blood pressure without a source or associated

with any other disease

- Most common form of hypertension

2. Secondary:- Elevation of blood pressure associated with another

disease such as kidney disease

HYPERTENSION

Category Systolic mmHg Diastolic mmHg

Optimal < 120 < 80

Normal < 130 < 85

High Normal 130 - 139 85 - 89

Hypertension Stage I 140 - 159 90 - 99

Hypertension Stage II 160 - 179 100 - 109

Hypertension stage III ≥ 180 ≥ 110

Causes

Genetics-some people are prone to hypertension simply based off of their genetic makeup

Family History- your risk for high blood pressure/hypertension increases if it is in your family history

Environment

– Inactivity

– Stress

– Obesity

– Alcohol

– High Sodium Diet

– Tobacco Use

– Age

– Menopausal Medications

Treatments Step 1:

– Lifestyle modifications • Diet and exercise• Limit alcohol and tobacco use• Reduce stress factors

Step 2:– If lifestyle changes are not enough,

drug therapy will be introduced Step 3:

– If previous steps don’t work, drug dose or type will be changed or another drug is added

Step 4:– More medications are added until blood pressure is controlled

RESPIRATORY EMERGENCIES

36MANAGEMENT OF MEDICAL EMERGENCIES IN DENTAL

PRACTICE - 60

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.

ASTHMA

Predisposing factors-INTRINSIC & EXTRINSIC

EXTRINSIC 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 – IgE antibodies produced in response to allergen

Approximately, 50% asthmatic children become symptomatic before reaching adulthood

INTRINSIC OR IDIOSYNCRATIC OR NON-ATOPIC ASTHMA

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.

CAUSATIVE FACTORS

Allergy

Respiratory infection

Physical exertion

Pollution

Occupational stimuli

Pharmacologic stimuli

Psychologic factors

MANIFESTATIONS

MILD SEVERE Wheezing Dyspnoea Tachycardia Coughing Anxiety

Intense dyspnoea with flaring of nostrils

Use of accessory muscles

Cyanosis of mucous membrane & nailbed

Flushing of face & anxiety

MANAGEMENT

Episode terminates Episode continues

Continue treatment Administer O2

Injection of aqueous epinephrine

Hydrocortisone sodium succinate 100-200mg iv

HYPERVENTILATION

CLINICAL MANIFESTATIONS

Palpitations

Tachycardia

Dizziness

Light headedness

Numbness of extremities

Chest pain

Dryness of mouth

Short breath

Muscle pain and cramps

Tremors

Stiffness

Tension

Anxiety

Excessive rate and depth of respiration leading to abnormal loss of carbon dioxide from the blood primarily predisposed to anxiety.

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

MANAGEMENT

Terminate dental treatment

Position-sitting

Verbally calm the patient

 Carbon dioxide rich air (paper bag)

if it continues

Diazepam 10mg IM/ IV 

Monitor vital signs

Continue dental treatment

AIRWAY OBSTRUCTION During dental treatment the potential is great that objects may fall into the posterior

portion of the oral cavity and subsequently into the pharynx.

PREVENTION Rubber dam

Oral packing

Chair position

Suction

Magill intubation forceps

Ligature

MANAGEMENTRECOGNITION OF THE AIRWAY OBSTRUCTION

Signs of complete airway obstruction

Inability to speak, breathe, cough

Universal sign for choking (choking sign)

Panic

Signs of partial airway obstruction

Forceful cough

Wheezing between coughs

Ability to breathe

Altered voice sounds

Possible disorientation

‘Crowing’ sound on inspiration

BASIC AIRWAY MANEUVERS

Position Head tilt- chin lift A+B Jaw thrust maneuver Artificial ventilation

ESTABLISHMENT OF EMERGENCY AIRWAY

Non invasive

Invasive

Back blows

Finger sweepChest thrustHeimlich maneuver

Manual thrusts

Non invasive

Tracheostomy

Cricothyrotomy

DIABETES MELLITUS

Serum glucose level can fall because of:

Increased administration of insulin

Decreased dietary caloric intake

Increased metabolic utilization of glucose (exercise, emotional

stress

WHIPPLE’S TRIAD:

1. Symtoms consistent with hypoglycaemia

2. Low plasma glucose concentration measured by precise method (Not with glucose monitor)

3. Relief of symptoms after plasma glucose level is raised.

Types of diabetes mellitus

Type 1-(beta cell destruction ,usually leading to absolute

insulin deficiency)

Type 2-(due to progressive insulin secretory defect on the

background of insulin resistance)

Gestational diabetes mellitus (GDM)-diabetes diagnosed

in the second or third trimester of pregnancy .

Pathophysiology of Hyperglycemia

Prolonged lack of insulin ( type1) or prolonged lack of tissue response(type2).

Blood glucose levels remains elevated for longer time because of glycogenolysis and decreased uptake by peripheral tissues.

Glucose exceeds 180mg/100ml-glucosuria

Clinical manifestations of hyperglycemia

symptoms:

Polyuria

Polydipsia

Polyphagia with weight loss

Recurrent blurred vision

pruritis

Loss of stength

Noctural enuresis

HypoglycaemiaBlood glucose level below 50 mg% usually indicates hypoglycemia in adults, less than 40mg% in children.

Clinical manifestations Rapid onset

Sweating

Tachycardia

Anxiety

Irritability

Disorientation

Nausea

MANAGEMENT

Terminate all dental treatment

Administer glucose source

monitor vital signs

If symptoms do not rapidly improve administer 30ml of

50% Dextrose solution IV

1mg glucagon IV or IM

0.5mg of 1:1000 epinephrine IM/ SC (every 15 Minutes)

THYROID GLAND DYSFUNCTION

Eye signs VON GRAEFE’S SIGN – Lid lag.

JOFFROY’S SIGN – Absence of wrinkling

of forehead on looking up.

STELLWAG’S SIGN – Decreased

frequency of blinking.

DALRIMPLE’S SIGN – Lid retraction

exposing the upper sclera.

MOBIUS SIGN – Absence of convergence.

MANAGEMENT

Euthyroid - patient with normal hormone levels can be managed normally

Hypothyroid – avoidance of CNS depressants (opiods, sedative hypnotics)

Hyperthyroid - avoidance of atropine and vasoconstrictors, least

concentrated solution is preferred 1:200,000, smallest

effective volume of anesthetic and vasodepressor, aspiration

prior to every injection

P – Position , supine position with feet elevated

D – Definitive management – activate Emergency Medical Services and if recovery

is not immediate, establish IV access

Hypothyroidism –IV doses of thyroid hormones (T3 & T4) for several days

Thyrotoxicosis –administer large doses of antithyroid drugs, additional therapy –

propranolol, glucocorticoids

Administer O2

Discharge or hospitalize the patient

SEIZURES

A seizure is defined as an episodic disturbance of movement,

feeling, or consciousness that can be caused by sudden

synchronous, inappropriate, and excessive electrical discharges

that interfere with the normal function of the brain.

The term epilepsy is defined as a disease of frequent

seizures that do not have a reversible metabolic cause

Epilepsy can be caused by either abnormal neuronal membrane

function or an alteration between the excitatory and inhibitory

neurons

Pathophysiology In epilepsy abnormal neurons

undergo spontaneous firing

Cause of abnormal firing is unclear

Firing spreads to adjacent or distant

areas of the brain

Often area of brain from which

epileptic activity arises.

MANAGEMENT OF SEIZURES

Treatment

Anti - epileptic drugs:

ABC’ (+ monitor / O2 /

large iv’s)

Start pharmacotherapy

immediately

Metabolic acidosis common

- if severe, give sodium

bicarbonate

Benzodiazepines

Phenytoin / fosphenytoin

Barbiturates

Others / new possibilities

CARDIOVASCULAR EMERGENCIES

65MANAGEMENT OF MEDICAL EMERGENCIES IN DENTAL

PRACTICE - 60

ANGINA PECTORIS

MYOCARDIAL INFARCTION

ANGINA PECTORISANGINA PECTORIS Definition- “A condition marked by severe pain in the chest, often also

spreading to the shoulders, arms, and neck, owing to an inadequate 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.

ANGINA PECTORIS

PREDISPOSING FACTORS

Physical activity

Hot humid environment

Cold weather

Large meals

Emotional stress

Fever, anaemia or thyrotoxicosis.

Cigarette smoking

High altitudes

CLINICAL MANIFESTATIONS

Chest pain

Radiation of pain

PREVENTION

Long acting nitrates- isosorbide dinitrate

Beta blockers- atenolol

Calcium channel blockers- verapamil, nefedepine

Nitroglycerine

Drugs

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 nitroglycerineOr 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

MANAGEMENT

MYOCARDIAL INFARCTIONMYOCARDIAL 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 diseaseCoronary thrombosis, occlusion and spasmMales5th and 6th decades of lifeUndue stress

MANAGEMENTMANAGEMENT Protocol common for both ACS outcomes

PORTABLE AUTOMATIC PORTABLE AUTOMATIC EXTERNAL EXTERNAL DEFIBRILLATOR (AED)DEFIBRILLATOR (AED)

Immediate recognition of cardiac arrest and activation of the

emergency response system.

Early CPR with an emphasis on chest compressions

Rapid defibrillation

Effective advanced life support

Integrated post-cardiac arrest care.

DRUG DRUG RELATED RELATED

EMERGENCIESEMERGENCIES73MANAGEMENT OF MEDICAL

EMERGENCIES IN DENTAL PRACTICE - 60

CLINICAL MANIFESTATIONSCLINICAL MANIFESTATIONS Confusion, blurred speech

Muscular twitching, facial tremor

Headache, tinnitus

Drowsiness, disorientation

Elevated BP,HR,RR

If uncontrolled, generalized tonic

clonic seizures.

MANAGEMENTMANAGEMENT Termination of the dental procedure

Positioning the patient comfortably

Reassurance of the patient

Basic life support ( BLS) as needed

Definitive care

Administration of O2

Monitoring of vital signs ( Blood pressure, heart rate and respiratory rate)

Administration of an anticonvulsant drug, if needed : Diazepam or midazolam

Gingivitis :- 91% Anaemia :- 82%Taste Alteration :-66%Halitosis :-52%Xerostomia :-48%

Morning Sickness :-48% Burning Sensation :-42% Pigmentation :-34% Tongue Changes :-17% Angular Cheilitis :-8%

Oral FindingsManagement in Pregnancy

Preventive Program

General Guidelines For Management

An accurate History

Preventive Oral Hygiene Measures

Short Appointment in Patients convenience

Treatment Timing

Drug Administration During Pregnancy

FUNCTIONAL EMERGENCIES

NEEDLE STICK NEEDLE STICK INJURYINJURY

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.

Invariably associated with faulty

techniques such as:

bending the needle while

administering LA

inserting the needle up to the

hub

directing 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.

NEEDLE NEEDLE BREAKAGEBREAKAGE

MANAGEMENTMANAGEMENT Inform pt of the occurrence, 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.

Basic Life Support

Primary response to all emergencies

P-A-B-C-D

Position >Airway >Breathing >Circulation

>Defebrilation

P-A-B-C-D MODIFIED TO

P-C-A-B-D

15 compressions – 2 rescue breaths

4 cycles – 1 minute

Cardio Pulmonary ResuscitationCPR

Steps in CPR Recognize cardiac arrest

Check for unresponsiveness

SHAKE AND SHOUT

CPRCardio Pulmonary Resuscitation

ABC of CPR A – Airway

B- Breathing

C- Circulation

Airway

Head tilt / chin lift

Sniffing morning air position Jaw thrust method

Check for Carotid pulse

Breathing Look for rise and fall of chest

Listen and feel for movement of airBreathing

Mouth to mouth

Mouth to nose

Endotracheal intubation

Oesophageal obturator airway

Position of hands to administer chest compression

OFFICE EMERGENCY KIT Oxygen, Ambu bag with mask Suction Syringes and needles Tourniquets Cricothyrotomy equipment Airways, laryngoscope

Epinephrine Diphenhydramine Diazepam Hydrocortisone Morphine Dextrose 50%

FUTURE OF CPR“DON’T WORRY ABOUT BEING

SCRUTINIZED FOR DOING IT

RIGHT-DOING SOMETHING IS

BETTER THAN DOING NOTHING”

CONCLUSION Commonly seen signs and symptoms include alterations of

consciousness, respiratory distress, seizures, drug related

emergencies and chest pain.

In each situation a successful outcome depends on our

adherence to defined treatment protocol.

Once such steps are employed successfully additional

(secondary) steps can lead us towards a more definitive

diagnosis which can help correct the problem.

REFERENCES

 

1. Medical emergencies in dental office- Stanley F. Malamed

2. Medicine 3rd Edition- K.George Mathew

3. Contemporary oral and maxillofacial surgery- Peterson

5. Principles and practice of medicine-Davidson