Medical Emergencies In Dentistry - II

By CYRIAC JOHNFINAL YR, PART I

• Unconsciousness - Vasodepressor syncope - Postural Hypertension - Acute adrenal insufficiency• Respiratory Distress - Foreign body airway obstruction - Hyperventilation - Asthma - Heart failure and acute pulmonary edema

CLASSIFICATON

• Altered Consciousness1. Diabetes Mellitus - Hyperglycemia - Hypoglycemia2. Thyroid gland dysfunction3. Cerebrovascular accident

• Seizure• Drug related emergencies - Drug overdose reactions - Allergy• Chest pain - Angina Pectoris - Acute Myocardial InfarctionSudden cardiac arrest

HYPERTENSIONDEFINITION“ABNORMALLY HIGH BLOOD PRESSURE CREATING SIGNS AND SYMPTOMS TO THE PATIENT”

RISK FACTORS• ATHEROSCLEROTIC VASCULAR DISEASE

• HISTORY OF HYPERTENSION

PRECIPITATING FACTORS• STRESS• FAILURE TO TAKE MEDICATION

DIAGNOSIS• HEADACHE • DIZZINESS• TACHYCHARDIA• PALPITATION• CONFUSION• NUMBNESS• LOSS OF LIMB FUNCTION

TREATMENT• SIT UPRIGHT

• 100 % OXYGEN

• CALL EMERGENCY SERVICES

• ANTIHYPERTENSIVE DRUGS

PREVENTION• CHECK BLOOD PRESSURE BEFORE PROCEDURE

• ASSURE MEDICATIONS

• STRESS REDUCTION PROTOCOLS

• MONITOR EPINEPHRINE DOSES

ANGINA PECTORISDEFINITION

“A CHARACTERISTIC THORACIC PAIN,USUALLY SUBSTERNAL PERCIPITATED CHEIFLY

BY EXERCISE AND MOTION OR A HEAVY MEAL;RELIEVED BY VASODILATOR DRUGS

AND A FEW MINUTES REST;AND A RESULT OF A MODERATE INADEQUACY OF THE

CORONAL CIRCULATION”

PREVENTION

• PROPER MEDICAL HISTORY • THE PAST MEDICAL HISTORY IN DETAIL

DENTAL THERAPY CONSIDERATION

• AVOID OVER STRESSING THE PT

• SUPPLEMENTAL OXYGEN BY A NASAL CANNULA – 3 – 5 L/MIN

• PAIN CONTROL DURING THERAPY, APPROPRIATE USE OF LA, SMALLER DOSE WITH

MAX. EFFECT – SLOW ADMINISTRATION

• VASODEPRESSOR ADMINISTRATION SHOULD BE MINIMISED IN INCREASED RISK PT

• MONITORING VITAL SIGNS• NITROGLYCERINE PREMEDICATION 5MINS BEFORE TREATMENT

CLINICAL MANIFESTATIONS• PAIN- SUDDEN ONSET OF CHEST PAIN• DULL ACHING HEAVY PAIN LOCATED SUBSTERNALLY• RADIATION OF PAIN – MOST COMMONLY TO THE LEFT SHOULDR AND ARM,

LESS FREQUENTLY TO RIGHT SHOULDER ARM, LEFT JAW, NECK AND EPIGASTRIUM

• PAIN- SUDDEN ONSET OF CHEST PAIN• DULL ACHING HEAVY PAIN LOCATED SUBSTERNALLY• RADIATION OF PAIN – MOST COMMONLY TO THE LEFT SHOULDR AND

ARM, LESS FREQUENTLY TO RIGHT SHOULDER ARM, LEFT JAW, NECK AND EPIGASTRIUM

ACUTE MYOCARDIAL INFARCTION

• IT IS A CLINICAL SYNDROME CAUSED BY A DEFFICIENT CORONARY ARTERY BLOOD SUPPLY TO A REGION OF MYOCARDIUM THAT RESULTS IN CELLULAR DEATH AND NECROSIS.

PREDISPOSING FACTORS

• ATHEROSCLEROSIS AND CORONARY ARTERY DISEASE.• CORONARY THROMBOSIS, OCCLUSION AND SPASM

CLINICAL FEATURES• MALES• 5TH AND 6TH DECADE OF LIFE• UNDUE STRESS

SYMPTOMS

• PAIN- CRUSHING, CHOCKING, PROLONGED , UPTO 30 MINS• RADIATES TO LEFT ARM, HAND, SHOLDER, EPIGASTRIUM , NECK AND

JAW• NAUSEA AND VOMITING, DIZZINESS, PALPITATION• COLD PERSPIRATION• FEAR OF IMPENDING DOOM

SIGNS

• RESTLESSNESS• ACUTE DISTRESS• SKIN – COOL, PALE AND MOIST• HEART RATE – BRADYCARDIA TO TACHYCARDIA

DENTAL THERAPY CONSIDERATIONS

• AVOID OVER STRESSING THE PT

• SUPPLEMENTAL OXYGEN BY A NASAL CANNULA – 3 – 5 L/MIN

• PAIN CONTROL DURING THERAPY, APPROPRIATE USE OF LA, SMALLER DOSE WITH MAX. EFFECT – SLOW ADMINISTRATION

• VASODEPRESSOR ADMINISTRATION IS A RELATIVE CONTRAINDICATION.

• PSYCHOSEDATION – NITROUS OXIDE AND OXYGEN IS PREFERRED

• IT IS STRONGLY RECOMMENDED THAT ELECTIVE DENTAL CARE IS AVOIDED UNTIL ATLEAST 6 MONTHS AFTER MI

• MEDICAL CONSULTATION AND ANTICOAGULATION AND ANTIPLATELET THERAPY NEED NOT BE ALTERED

• INFERIOR ALVEOLAR NERVE BLOCK AND PSA NERVE BLOCK – RISK OF HEMORRHAGE – SHOULD BE AVOIDED

PREVENTION

• PROPER MEDICAL HISTORY • THE PAST MEDICAL HISTORY IN DETAIL• VITAL SIGNS SHOULD BE RECORDED BEFORE AND

IMMEDIATELY AFTER DENTAL APPOINMENTS• VISUAL EXAMINATION – PERIPHERAL CYANOSIS, COOLNESS

OF EXTREMITIES, PERIPHERAL EDEMA, POSSIBLE ORTHOPNEA

POSTURAL HYPOTENSION

“DECREASED BLOOD PRESSURE ASSOCIATED WITH AN ABRUPT CHANGE IN PT POSITION”• ORTHOSTATIC HYPOTENSION

PRECIPITATING FACTORS

• RAPID VERTICAL CHANGE IN BODY POSITION IN PERSONS AT RISK• DEHYDRATION• BLOOD LOSS• ALLERGIC REACTION• MI

CLINICAL FEATURES/DIAGNOSIS

• PT FEELS LIGHT HEADED UPON RAPID STANDING• LOSS OF CONSCIOUSNESS• VITAL SIGNS SHOWBLOOD PRESSURE LOW PULSE NORMAL OR RAPID

TREATMENT AND MANAGEMENT

• STOP DENTAL TREATMENT• REMOVE OBJECTS IN MOUTH• RAISE FEET• LOOSEN THE CLOTHING• SUPPLEMNTAL OXYGEN• COOL TOWEL TO FOREHEAD• MONITOR VITAL SIGNS

PREVENTION• DO NOT ALLOW THE PTs AT RISK TO RAPIDLY STAND FROM THE DENTAL

CHAIR• ELEVATE THE PATIENTS SLOWLY AND IN STAGES• BE PREPARED TO PHYSICALLY SUPPORT THE PATIENT IF THEY PASS OUT

BACTERIAL ENDOCARDITIS

DEFINITION“Infective endocarditis is defined as microbial infection of the endothelial surfaces of the heart or iatrogenic foreign bodies like prosthetic valves and other intracardiac devices.”

PREDISPOSING FACTORS

• Numbers of bacteria entering the blood• Ability of bacteria to adhere to endocardium• Congenital• Rheumatic and other acquired valvular disease• Prosthetic heart disease

MANAGEMENT

• A CONSENT LETTER FROM THE DR OVERLOOKING THE PT-STATING PATIENT IS FIT FOR DENTAL PROCEDURES

• Early treatment needed to minimize the cardiac damage. The usual treatment is intravenous penicillin plus gentamycin for 2 weeks or more if viridians streptococci is the causative orgm

DENTAL TREATMENT UNDER - LAClinical Situation

Drug Regimen

Patients not allergic to pencillin

Amoxillin ADULTSOral amox 3g 1hr. Before procedureCHILD<5yrs : oral amox-250mg 1 hr. B.Pr5-10yrs : oral amox-500mg 1 hr. B.Pr>10yrs : use adult dose

Patient allergic to pencillin

Clindamycin ADULTSOral clindamycin 600mg 1 hr before pr.

CHILD<5 yrs- Oral Clindamycin 150 mg 1hr. Before pr.5-10 yrs- oral clindamycin 300mg 1 hr. bef pr.<10 yrs – Use adult dose

UNDER GACLINICAL SITUATION

DRUG REGIMEN

Patient not allergic to penicillin

Amoxicillin ADULTSi.v. amox 2g administered upon attainment of GA and immediately bef pr.CHILD<5yrs-i.v. amox 250mg administered upon attainment of GA 5-10yrs-oral amox 500mg administered 1 hr. bef pro.>10yrs- Use adult dose 2g administered before procedure

Treatment needing Antimicrobial prophylaxis in pts at risk of IE

• Extractions• Sub gingival procedures – Probing/card

placement.• Oral/Periodontal implant surgery & flap surgery.• Endodontics beyond the root apex.• Sialography• Intraligamental LA• Rubber dam matrix/Wedge placement

Procedure in which antimicrobial prophylaxis NOT reqd in persons at risk of Infective Endocarditis

• Dental Radiography• Endodontics beyond apex.• Exfoliation of primary teeth.• Impression taking.• Non surgical procedures that not have bleeding.• Abscess incision and drainage.• Suture removal, orthodontic band removal

MEDICAL EMERGENCIES DUE TO

FUNCTIONAL CAUSES

IATROGENIC CAUSES ARE MAINLY• NEEDLE BREAKAGE• SWALLOWING OF DENTAL & SURGICAL MATERIALS• INJURY TO SOFT TISSUE• INFECTION

NEEDLE BREAKAGEMAIN CAUSE OF NEEDLE BREAKAGE IS DUE TO• USING INAPROPRIATE NEEDLE SIZE FOR PROCEDURES• INJECTING WITHOUT STABILIZING THE SYRINGE BY HOLDING

THE HUB OF THE NEEDLETREATMENT AND MANAGEMENT• INFORM AND ENSURE THE PATIENT ABOUT THE INCIDENT• WITH PROPER CARE AND ASSISTANCE,SURGICALLY REMOVE

THE BROKEN SEGMENT• PROVIDE POST SURGICAL INSTRUCTIONS AND MEDS

SWALLOWING OF DENTAL AND SURGICAL MATERIALS

TREATMENT AND MANAGEMENT• INFORM AND ENSURE THE PT• INDUCE VOMITING• GASTRIC LAVAGE• MILK THERAPY

INJURY TO SOFT TISSUESCausesAccidental slipping of instrumentsInappropriate surgical practicesTreatment and managementInform and ensure the patientControl the bleeding if presentGive appropriate medications and instruction

• InfectionCauses• Unsterile instruments• Unhygienic practices• Unsterile environment(clinical surrounding)• Using one instrument for multiple procedures in diff pts without

disinfection and sterilizationManagement• Sterilize every instrument before starting treatment on a new

patient• Keep the clinical environment clean and sterile

DRUG OVERDOSE REACTIONSOVERDOSE IS A CONDITION THAT RESULTS FROM EXPOSURE TO TOXIC AMOUNTS OF A SUBSTANCE THAT DOES NOT CAUSE ADVERSE EFFECTS WHEN ADMINISTERED IN SMALLER AMOUNTS.

DRUGS AND ADVERSE REACTIONS• LOCAL ANAESTHETIC• ANTIBIOTICS• ANALGESICS• SEDATIVE HYPNOTICS

• LOCAL ANAESTHETICS ESTERS

ALLERGY – common, especially with topical anesthetics, manifested as localized erythema and edema.

Overdose – unlikely with esters, unless genetic deficiency present

Side effects – rare sedation or drowsiness

Management – antidote to la overdose is phentolamine mesylate

• AMIDESALLERGY - MOST CLINICAL REPORTS PROVED ALLERGY TO BE PSYCHOGENIC RXN, OVERDOSE OR ALLERY TO OTHER COMPONENT OF SOLUTION

OVERDOSE – CNS DEPRESSION MANIFESTED AS DROWSINESS, TREMOR, TONIC CLONIC SEIZURES

SIDE EFFECTS – RARE, SEDATION MOST COMMON

• ANTIBIOTICSALLERGY – HIGH ALLERGIC POTENTIAL TO MANY ANTIBIOTICS MANIFESTED CLINICALLY OVER ENTIRE SPECTRUM OF ALLERGIC PHENOMENA.

OVERDOSE – VIRUALLY NON EXISTENT WITH PENICILLIN

SIDE EFFECTS – RARE GI UPSET – MOST COMMON

• ANALGESICSNON OPIOID ALLERGY – HIGH ALLERGY POTENTIAL (ASPIRIN)OVERDOSE – COMMON SALICYLISM

OPIOIDSALLERGY – UNCOMMONOVERDOSE - COMMON, MANIFESTED AS CNS DEPRESSION AND RESPIRATORY DEPRESSIONSIDE EFFECTS – MOST COMMON ADR, MANIFESTED CLINICALLY AS NAUSEA, VOMITING, ORTHOSTATIC HYPOTENSION

• SEDATIVE HYPNOTICSBENZODIAZEPINES OVERDOSE – CNS DEPRESSION MANIFESTED AS OVER SEDATIONSIDE EFFECTS- PROLONGED DROWSINESS

INHALATION SEDATION (N20-02)OVERDOSE – COMMON, MANIFESTED AS OVER SEDATIONSIDE EFFECTS – MOST COMMON AREA MANIFESTED AS NAUSEA, VOMITING

• MANAGEMENTMANAGEMENT OF OVER SEDATION FOCUSES ON DEREASE IN PERCENTAGE OF N2O THROUGH AN INCREASE IN THE VOLUME OF FLOW OF O2 COUPLED WITH THE STEPS OF BLS. P-A-B-C UNTIL THE PT REGAINS CONSCIOUSNESS.

• Prompt recognition and efficient management of medical emergencies by a well prepared dental team can increase the likelihood of satisfactory outcome.

• The basic aim for managing medical emergency is to ensure that the pts brain receives constant supply of blood containing oxygen.

Conclusion

• Medical emergencies in dental office: Stanley F Malamed• Mark greenwood dental emergencies

References

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