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MEDICAL EMERGENCIES IN COMMUNITY

Presented by: Jigyasha timsina Batch 2011

Emergency An unforeseen combination of circumstances or the

resulting state that calls for immediate action

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WHY FOCUS ON MEDICAL EMERGENCIES???

Does not allow time for orderly information gathering and formulation of a narrow differential diagnosis before the initiation of therapy.

“When you prepare for emergency, the emercency ceases to exist”

APPROACH TO A MEDICAL EMERGENCY

Comprehensive medical history Vigilant observation & prompt PREVENTION recognition of symptoms of an emergency

Basic life support PREPARATION

Affiliation to definitive medical care

Did you know ??? A person who receives BLS has 20%increase in survival rate than one who does not…so just act..

Emergency drug kit ADA suggests that following drugs

should be included as minimum in emergency kit.

1. Oxygen2. Epinephrine 1:1000(injectable)3. Nitroglycerin (sublingual tablet or

aerosol spray)4. Histamine blocker (injectable)5. Bronchodilator (asthma

inhaler - salbutamol)6. Aspirin7. Oral carbohydrate

Other drugs Glucagon

Atropine Ephedrine Corticosteroids Morphine Naloxone Nitrous oxide Injectable benzodiazepine Flumazenil

Most CommonEMERGENCIES

SYNCOPE SEIZURE

TRAUMA

ASTHMATIC ATTACK

HYPOGLYCAEMIA

AIRWAY OBSTRUCTION

ALLERGIES

CHEST PAIN DRUG TOXICITY

SYNCOPE

Defined as a short loss of consciousness and muscle strength, characterized by a fast onset, short duration, and spontaneous recovery

CAUSES

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Clinical symptoms Presyncope

Syncope

Postsyncope

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Presyncope Early

Feeling of warmth Loss of skin colour Heavy perspiration Complaints of feeling ill Nausea Hypotension Tachycardia

Late Pupillary dilatation Hyperpnea Cold hands and

feet Hypotension Bradycardia Visual disturbances Dizziness

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Syncope Breathing

Irregular, jerky and gasping Dilated pupils – death like appaerance Convulsive movements Bradycardia < 50 beats/min Weak thready pulse Loss of consciousness Partial or complete airway obstruction

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Postsyncope Pallor Nausea Weakness Sweating

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MANAGEMENT

Position: supine position with brain and heart at same level with feet elevated slightly (10 to 15 degree)

ABC – Basic life support as needed

Definitive management : Monitor vital signs Administer aromatic ammonia Administration of atropine

(0.1mg/ml)

If delayed recovery seek medical assistance

SEIZURE• A paroxysmal disorder of cerebral

function characterized by an attack involving changes in the state of consciousness ,motor activity or sensory phenomena.

• Usually sudden in onset and of brief duration.

EPILEPSY- “A chronic brain disorder of various etiologies characterized by recurrent seizures”

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Common symptoms

PREVENTIONIf pt is a known epileptic, make sure he/she

has taken their regular dose of anti-convulsant on the day of treatment.

Instruct him/her to alert you as the aura of the impending seizure manifests itself.

Keep life support equipment ready in case of an emergent status epilepticus.

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Management Self limiting emergency

Position : supine with patient placed on flat surfaces

Remove dangerous objects from the mouth and around the patient eg. sharp instruments, needles, etc.

Loosen any tight clothing.

Avoid restraining the patient

In case the ictus fails to subside within a maximum of 10 minutes, declare status epilepticus and proceed with definitive care.

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Definitive treatment

Diazepam 10 mg iv (2mg/min)repeat every 10 min

Phenobarbitone (100- 200mg/min) iv

Hypoglycemia Hypoglycemia is a clinical

syndrome in which low serum (or plasma) glucose levels lead to symptoms of sympatho- adrenal activation.

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Management Glucose and sugar-containing beverages

administered orally to conscious patients for rapid effect.

Alternatively, milk, candy bars, fruit, cheese, and crackers may be adequate in mild cases

IV dextrose is indicated for severe hypoglycemia, in patients with altered consciousness and during restriction of oral intake.

An initial bolus, 20-50 mL of 50% dextrose, should be given immediately.

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Glucagon, 1 mg IM (or SC), is an effective initial therapy for severe hypoglycemia in patients unable to receive oral intake or in whom an IV access cannot be secured immediately.

TRAUMA • Trauma refers to damage, impairment or external

voilence producing injury or degeneration.

• Trauma of the oral and maxillofacial region occur frequently

• comprises 5% of all injuries for which people seek treatment.

• Among all facial injuries, dental injuries are the most common, of which crown factures and luxations occur most frequently.

• The most common location is the anterior maxilla followed by the anterior mandible.

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A traumatic injury in a maxillofacial region can result in:

- Fractures of the jaws - Fractures of the teeth - Soft tissue injuries - Injuries to vital stuctures

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Management:

Avoid patient movement before determining extent of trauma

Airway: Chin lift. Jaw thrust. Manually move the tongue forward. Maintain cervical immobilization

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Hemorrhage control

Maxillofacial bleeding:Direct pressure.

Nasal bleeding:Direct pressure.Anterior and posterior packing.

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• First aid should be given for the injuries occurred.

• The patient should be referred to the nearby higher centres for further diagnosis and care

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Chest pain

Includes commonly : Angina pectoris Myocardial infarction

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Angina PectorisAngina is defined as“a characteristic

thoracic pain, usually substernal; precipitated chiefly by exercise, emotion, or a heavy meal; relieved by vasodilator drugs and a few minutes rest; and a result of moderate inadequacy of the coronary circulation.”

Produced when myocardial blood supply cannot be sufficiently increased to meet the increased oxygen requirement that results from coronary artery disease.

Recognize the problem discontinue dental treatment

P- position patient comfortably

A,B,C –ascess airway, breathing and circulation

Definitive management

If history of angina existsAdminister vasodilator and O2 If pain resolvesConsider future dental treatment modificationMonitor vital signs

No history of anginaAdminister O2 and consider nitroglycerinMonitor and record

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Acute Myocardial Infarction Myocardial infarction is a clinical syndrome

caused by a deficient coronary arterial blood supply to a region of myocardium that results in cellular death and necrosis.

The syndrome is usually characterized by severe and prolonged substernal pain similar to but more intense and of longer duration than the angina pectoris.

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Acute myocardial infarction should be suspected if :

A first episode of chest pain suggestive of acute MI that occurs either at rest or with ordinary activity. It may develop during dental treatment especially if patient is dental phobic.

Change in previous stable pattern of pain

which may be increased in frequency or severity.

Chest pain is suggestive of MI in a patient with known CAD if relieved by rest or nitroglycerin.

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Recognize the problem(chest pain )

↓Discontinue the dental treatment

↓P—position patient comfortably

↓A→B→C—assess airway, breathing and circulation

↓D—definitive treatment

presumptive Dx :acute MI Administer O2, consider nitroglycerin Administer aspirin Manage pain(parenteral opoids) Monitor and record vital signs Prepare to manage complications(e.g. cardiac arrest) Stabilize and transfer to hospital emergency department

Management

No history of anginaAdminister O2 and consider nitroglycerinMonitor and record

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Airway Obstruction

Causes:

• Foreign body (usually food) • Infection or posttraumatic hematoma• Obstruction by the tongue • Trauma

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Presentation

• Stridor• Impaired or absent phonation• Choking and respiratory distress• Angioedema• Fever• Evidence of trauma

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Management• Is directed at rapid relief of obstruction to

prevent cardiopulmonary arrest and anoxic brain damage.

• Perform the head tilt and chin lift maneuver if cervical spine trauma is not suspected.

• Perform a jaw thrust if cervical spine trauma is suspected.

• Attempt to ventilate the patient with a bag-valve-mask apparatus.

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• Perform the Heimlich maneuver (subdiaphragmatic abdominal thrust) repeatedly until the object is expelled from the airway.

• If the situation cannot be managed, the patient should be referred to a nearby hospital or a health post.

Heimlich maneuver

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If the patient is unconscious:• Place the patient in supine position.

• Open patient’s airway by using head tilt chin lift technique.

• Place the heel of one hand against the victims abdomen in the midline slightly above the umbilicus & well below the xiphoid process.

• Place one hand on top of other hand.

• Press in to the victims abdomen with quick inward and upward thrust.

Asthma

A clinical state of hyper reactivity of the tracheobronchial tree, characterized by recurrent paroxysms of dyspnea and wheezing

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Signs and symptoms Feeling of chest tightness Dyspnea Tachypnea Cough Use of Accessory/Respiratory Muscles Agitations

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The most likely times for an acute exacerbation are:During and immediately after

local anesthetic administration. 

With stimulating procedures such as extraction.

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Management Discontinue the dental procedure and allow the

patient to assume a upright position.

Establish and maintain a patent airway and administer Beta 2 agonists via inhaler or nebulizer.

Administer oxygen  if possible If no improvement is observed and symptoms

are worsening, administer epinephrine subcutaneously (1:1,000 solution, 0.01 mg/kg of body weight to a maximum dose of 0.3 mg).

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Begin diligent basic life support.

Document in time form the beginning of the event.

Alert emergency medical services.

Maintain a good oxygen level until the patient stops wheezing and/or medical assistance arrives.

Escort patient to hospital as needed.

MANIFESTATIONS AND MANAGEMENT OF LOCAL ANESTHETICS OVERDOSE

50MANIFESTATIONS MANAGEMENT

MILD OVERDOSE Talkativeness, slurred speech, anxiety , confusion

Stop administration of

LA-Monitor all vital

signs-Observe for 1 hr

MODERATE TOXICITY

Slurring speech, nystagmus, tremor,headache, dizziness , blurred vision,drowsiness

-Stop administration of

LA-Place the patient in supine position

-Monitor vital signs

-Administer oxygen

-Observe in office for 1 hr

51SEVERE TOXICITY

Seizures, cardiac arrythymia or arrest

- Place the patient in supine positions - If seizures occur, protect the patient from nearby objects.- Suction the oral cavity if vomiting occurs.- Summon medical assistance.-Monitor vital signs.-Administer oxygen.-Start I.V infusion.-Administer diazepam 5-10mg slowly.-Provide basic life support.-Transport to emergency.

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Epinephrine (vasoconstrictor) overdose reactions

• Available concentrations are 1:50000, 1:100000, 1:200000.

• The optimal concentration for the prolongation of anaesthesia with lidocaine is 1:250000.

• Maximal dose: Healthy adult - 0.2 mg Cardiac patient - 0.04 mg

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Clinical manifestations:

Signs - Rise in blood pressure and heart rateSymptoms - Anxiety - Restlessness - Perspiration - Dizziness - Weakness - Pallor - Palpitation

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Management

Terminate the dental procedure Position the patient in upright position Reassure the patient Basic life support if indicated Monitor vital signs Summon medical assistance Administer oxygen

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TOXINS / DRUGS

TOXIC DOSE MANIFESTATIONS

MANAGEMENT SPECIFIC ANTIDOTES

1. Acetaminophen

>140mg/kg or at least 7.5g

AnorexiaVomitingDiaphoresis

GI decontaminationAdministration of activated charcoal

Acetylcysteine The total dose is 300 mg/kg, given as 3 separate doses

2. Anti-depressants(eg:amytryptilline, desipramine, imipramine)

20mg/kg causes few fatalities35mg/kg-approx lethal dose>50mg/kg-likely to cause death

MydriasisIleusUrinary retentionHyperpyrexia

GI decontaminationGastric lavage with activated charcoalIV sodium bicarbonate

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OPIOIDS Although opioids have been used as an

effective analgesic drug,most of the time,it has been used as an abusive product.

Opioid toxicity can result in: - Respiratory depression - Depressed level of consciousness - Miosis

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Treatment

Gastric lavage

Antidote(naloxone hydrochloride,initial dose of 2 mg IV)

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ALCOHOL

The toxicity of alcohol is dose related. Blood levels >100 mg/dL are associated

with ataxia. At 200 mg/dL, patients are drowsy and

confused. At levels >400 mg/dL, respiratory

depression is common and death is possible.

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Treatment

Administration of 100 mg thiamine IV .. Treat hypoglycaemia  with 50 ml of 50%

dextrose solution

Provide oxygen therapy as needed

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GENERALISED ANAPHYLAXIS

Acutely life threatening condition. Reactions develop rapidly 5-30 minutes. Signs and symptoms of generalised anaphylaxis are

highly variable.

Four major clinical syndromes are: 1. Skin reactions 2. Smooth muscle spasm 3. Respiratory distress 4. Cardiovascular collapse

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USUAL PROGRESSION OF ANAPHYLAXIS

Skin

Eye , Nose , GI

Respiratory system

Cardiovascular system

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MANAGEMENT

• Terminate dental procedure & stop administration of all drugs presently in use.

• Position the patient comfortably.• Basic life support as indicated.• Monitor vital signs.

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Definitive Management

No CVS or respiratory involvement: - Administration of oral or IM anti-

histamine.

CVS or respiratory involvement: - Reposition the patient - Administration of epinephrine - Administration of anti-histamines

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To conclude…. The first step in management of dental

emergencies is to prevent their occurrence

With proper knowledge medical emergencies and related complication can be easily prevented

“When you prepare for emergency, the emergency ceases to exist”

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REFERENCES Medical Emergencies In The Dental Office - 5th

Edition - Stanley F. Malamed Contemporary Oral and Maxillofacial Surgery – 5th

edition- Hupp,Ellis and Tucker Internet Sources

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