Medical emergencies in dentistry

Presented byR.Aysha sulthana

CRRI

Introduction

• Various emergency conditions arises in a dental operatory

• Basic method to avoid such condition is prevention

• Prevention : Complete information on the past medical history, thorough clinical examination and physical examination

Classification of medical emergency

• Syncope• Hypoglycemia • Epileptic episode • Angina• Myocardial infarct• Anesthetic overdose• Drug allergy anaphylaxis • Asthma

Continued..

• Respiratory distress• Postural hypotension• Adrenal crisis• Thyroid dysfunction• Drug overdose reaction• Postural hypotension• Hyperventilation• Obstruction due to foreign body

Precautions in dental office

• BLS certification• ACLS certification• Emergency drug kit• Preparation of dental surgeon and teaching

various methods to tackle such conditions given prime importance

ASA classification of physical status

• Class 1 : Healthy patients with no systemic disease

• Class 2 : mild systemic disease with no limits on activity

• Class 3 : severe systemic disease that limits activity

• Class 4 : incapacitating systemic disease that is life threatening

• Class 5 : moribund and emergency of any kind E

What is Anxiety recognition and stress reduction protocol ?

• Recognize patient’s anxiety level• Premedication or sedation• Minimize waiting time and appointment

length• Adequate pain control• Monitor vital signs• Medical counsel if required

Premedication drugs

DRUG RECOMMENDED DOSAGE FOR ADULTS

ALPRAZOLAM 4 mg /day

DIAZEPAM 2-10 mg

FLURAZEPAM 15-30 mg

TRIAZOLAM 125-250 mic g

ESZOPICLONE 2-3 mg

ZALEPLON 5-10 mg

ZOLPIDEM 10 mg

High risk category

• Prosthetic cardiac valves• Bacterial endocarditis• Cyanotic Congenital heart disease• Surgically constructed systemic pulmonary

shunts

Moderate risk category

• Acquired valvular dysfunction• Other congenital cardiac malformations• Hypertrophic cardiac myopathy• Mitral valve prolapse

Negligible risk category

• Isolated atrial septal defect• Surgical repair of ASD,VSD, patent ductus

arteriosus• Mitral valve prolapse• Heart murmurs• Rheumatic heart disease• Cardiac pacemakers and implanted

defibrillators

What is basic life support?

Advanced cardiovascular life support (ACLS)

Critical or essential emergency drugs – primary

category Generic drug Alternative Quantity Availability Allergy -anaphylaxis

epinephrine none 1 preloaded syringe + 1*3 ml ampules

1:1000 ( 1mg/ml)

Allergy- histamine blocker

chlorpheniramine

diphenyramine 3 * 1 ml ampules

10 mg/ml

Oxygen Oxygen 1 E cylinder

Vasodilator nitroglycerine Nitrostat sublingual tablets

1 metered spray bottle

0.4mg/metered dose

Bronchodilator Albuterol metaproterenol

1 metered dose inhaler

Metered aerosol inhaler

antihypoglycemic

sugar Insta glucose gel

1 bottle

Inhibitor of platelet aggregation

aspirin none 2 packets 325mg/tablet

critical drugs continued..

Oxygen delivery system

Positive pressure and demand valvePocket mask

Oxygen delivery system with bag valve mask device

Minimum 1 large per adult

Automated electronic defibrillator

1 AED

Syringes for drug administration

Plastic disposable syringes with needles

3*2 ml syringes with needles for parenteral drug administration

Suction and suction tips

High volume suction,larger diameter,round ended suction tips

Non electrical suction system

Office suction system minimum 2

Tourniquets Robber and velcro tourniquet,rubber tubing

Sphygmomanometer

3 tourniquets and 1 sphygmomanometer

Magill intubation forceps

Magill intubation forceps

1 pediatric magill intubation forceps

Secondary - non critical drugs

Anti convulsant Midazolam Diazepam 1 * 5 ml vial 5 mg/ml

Analgesic Morphine sulphate

Merperidine 3*1 ml ampule 10 mg/ml

Vasopressor Phenyl ephrine Glucagon 3* 1 ml ampule 10 mg/ml

Anti hypoglycemic

50 /- dextrose 1 vial 50 ml ampule

Corticosteroid Hydro cortisone sodium succinate

Dexamethasone

2 *2 ml mix –o-vial

50 mg/ml

Anti hypertensive

Esmolol Propanalol 2 * 100 mg/ml vial

100 mg/ml

Anti cholinergic Atropine Scopalamine 3 *1 ml ampule 0.5 mg/ml

Repiratory stimualant

Aromatic ammonia

2 boxes 0.3 mg/vaporole

Anti hypertensive

Nifedipine 1 bottle 10 mg capsule

antidotal drugs

Opioid antagonist

Naloxone Nalbuphine 2 * 1 ml ampules

0.4 mg/ml

Benzodiazepine antagonist

Flumazenil 1 * 10 ml vials 0.1 mg/ml

Anticholinergic toxicity

Physostigmine 3 * 2 ml ampules

1 ml

Anti emergence delirium

Advance cardiac life support drugs

Cardiac arrest Epinephrine 3 * 10 ml preloaded syringe

1:10,000

Analgesic Morphine sulphate

N2O-O2 3 * 1 ml ampules

100 mg/ml

Antidysrhythmic

Lidocaine Procinamide 1 preloaded syringe , 2* 5 ml ampules

100 mg/syringe

Symptomatic bradycardia

Atropine Isoproterenol 2* 10 ml syringes

1.0 mg/10ml

Paroxysmal supraventricular tachycardia

Verampamil 2 * 4 ml ampules

2.5 mg/ml

Syncope• Sudden, transient loss of consciousness that

occurs secondary to the period of cerebral ischemia

• Freight• Anxiety• Receipt of unpleasant news• Emotional stress• Receipt of unwelcome news• Pain ( sudden and unexpected)• Sight of blood surgical / dental instruments

Non psychogenic factors

• Erect sitting• Hunger from dieting• Exhaustion• Poor physical condition• Hot humid crowded environment• Male gender• 16 and 35 years of age

• Assess consciousness• Activate office emergency system• Position • ABC• Perform additional procedures : administration of

aromatic ammonia valporate, atropine if bradycardia persists

• Postpone dental treatment• Identify causes• If delayed recover then activate EMS

Postural hypotension• Prolonged erect sitting• Recumbency or convalescene for longer time• Late stage pregnancy• Advance stage• Inadequate postural reflex• Advanced age• Venous defects in legs• Physical exhaustion and starvation• Recovery from sympathectomy• Addison disease• Chronic postural hypotension

Management

• Positioning with feet elevated slightly• ABC• Definitive care : administer o 2 and monitor

vital signs• If recovery : slow repositioning of chair• Delayed recovery : activate EMS• Continous BLS as needed and discharge

patient

Diabetes melliteus – hyperglycemia and hypoglycemia

• High levels of blood sugar due to defects in insulin production,action or both

• Type 1 diabetes melliteus• Type 2 diabetes melliteus

ASA PHYSICAL STATUS TREATMENT CONSIDERATION

II Eat normal breakfast and take usual insulin dose in the morningAvoid missing meals before and after surgeryIf missing meal is unavoidable consult physician or decrease dose by half

III Monitor blood glucose levels more frequently for several days following surgery and modify insulin accordinglyConsider medical consultation

IV Consult physician before treatment

Antibiotic prophylaxis

Management • Lack of response to sensory stimulation by dental

treatment• Discontinue dental treatment and activate office

emergency team• Supine position with legs elevated• Assess ABC• D definitive care : summon EMS• Establish IV infusion, 5 percent dextrose or of normal

saline• Administer o2• Transport to hospital

• Antibiotic coverage post surgical treatment• Stress reduction protocol• Monitoring of the surgical site

Thyroid gland dysfunction

• T3 ,t4 and calcitonin – regulation of biochemical activity of body tissues

• Prevention : medical history ,thorough clinical examination

• Clincal considerations : euthyroid patients with normal hormone levels can be managed normally

• Hypothyroid : avoidance of CNS depressants ( opioids, sedatives and hypnotics)

• Hyperthyroid : avoidance of atropine and vasoconstrictor. Least concentrated solution preferred 1:200000 . Smallest effective volume of anesthetic and vasodepressor,aspiration prior to every injection

• Evaluation of cardiovascular disease

Management • Supine position with feet elevated• Definitive management : activate EMS if recovery

is not immediate establish IV access• Hypothyroidism : iv doses of thyroid hormone for

several days• Thyrotoxicosis : administer larger doses of

antithyroid drugs• Additional therapy : propanolol , glucocorticoids• Administer O2• Discharge and hospitalise patient

Foreign body airway obstruction

What is adrenal crisis?

• Lack of glucocorticosteroid hormone• Sudden withdrawal of steroid hormone –

suffering from primary adrenal insufficiency• Temporary insufficiency by cortical suppression• Stress physiologic or psychologic• Bilateral adrenalectomy• Sudden destruction of pituitary gland • Injury to adrenal gland

Prevention

• Rheumatic fever, asthma , TB, emphysema.other lung disease, arthiritis , rheumatism

• Allergy to drug ,food ,medication and latex• RULE OF TWO : in a dose of 20 mg or more of

cortisone or its equivalent via oral or parenteral route of two weeks no longer

• Within 2 years of dental therapy

Management

• If conscious terminate dental treatment• Position patient comfortably if asymptomatic• Supine with legs elevated slightly• Assess ABC• D – definitive care• Monitor vital sign• Medical assistance• Admnister glucocorticosteroid

Hyperventilation

• Ventilation in excess• Increase in frequency or depth of respiration

or both• Common cause : extreme anxiety• Prevention : by prompt recognition• Vital signs• Stress reduction protocol

Management

• Position the patient usually upright • ABC• D definitive care : remove dental materials from

patient mouth and calm patient• Correct respiratory alkalosis : breathing of 3

percent co2 and 97 percent o2• Continue dental care if doctor and patient agrees• Discharge patient

Asthma

• Chronic inflammatory disorder characterised by reversible obstruction of the airways

• Allergens• Food and drugs• Type 1 hypersensitivity reactions• Psychological and physiological causes

• Stess reduction protocol• Contraindication of barbiturates and opioids• Inhalation anesthetics like ether cause

irritation• Careful prescription of analgesics• Sensitive to bisulphides LA is contraindicated

management

• Recognition of problem• Discontinue treatment• Activate office emergency team• Upright with arms thrown forward• ABC• D administer o2 • Sedatives strictly contraindicated ,IM

Diazepam to decrease anxiety

Drugs prescribed

• Administer bronchodilator by inhalation • Salmeterol• Aminophylline• Theophylline• Metaproterenol• Albuterol• Epinephrine• levabuterol

Heart failure and acute pulmonary edema

• Inability of heart to supply sufficient oxygenated blood for metabolic needs

• Increase in the workload – high blood pressure

• Coronary disease and acute myocardial infarction

• Pregnancy , anemia , hyperthyroidism, paget’s disease

• Psychological and climatic stress

• ASA I : No dyspnoea and fatigue with normal exertion. No special dental modification

• ASA II : mild dyspnoea and fatigue during exertion. Stress reduction protocol should be considered

• ASA III : dyspnoea and fatigue with normal activities. Medical consultation, stress reduction protocol and other treatment modification

• ASA IV : dyspnoea ,undue fatigue, orthopnoea at all times. Only elective procedures- dental emergencies managed with medication. Physical intervention only in hospital dental clinics

Acute pulmonary edema

• All signs and symptoms of heart failure• Moist rales at lungs• Tachypnoea• Cyanosis• Frothy pink sputum• Increased anxiety dyspnoea at rest

Management • Assess presence of consciousness and any difficulty in breathing• Position conscious patient in any comfortable position usually

upright• Activate office emergency team• ABC assessment• Definitive treatment : administer O2• Monitor vital signs• Alleviate symptoms of respiratory distress• Perform bloodless phlebotomy• Administer vasodilator eg: nitroglycerine• Alleviate apprehension eg: morphine• Discharge patient and modify subsequent dental treatment

Seizures PARTIAL SEIZURE GENERALISED SEIZURE

SIMPLE PARTIAL ABSENCE OF SEIZURE ( TRUE PETITMAL)

COMPLEX PARTIAL MYOCLONIC SEIZURES

PARTIAL SEIZURE EVOLVING TO GENERALISED

TONIC CLONIC SEIZURES

TONIC CLONIC UNCLASSIFIED EPILEPTIC SEIZURE

CAUSE

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

• Hypoxia,hyoglycemia,hypocalcemia• Flashing lights, fatigue, missed

meal,decreased physical strength,alcohol ingestion, physical or emotional stress, sleep and menstrual cycle

• Care in selection of LA• Conscious sedation N2O –O2 &

benzodiazepins

Management of petitmal seizure

• Position with feet elevated• If seizure ceases reassure the patient• Allow patient to recover before discharge• If seizure continues for more than 5 minutes• Assess ABC and perform BLS

Drug overdose reactions

• Management of toxic reactions to epinephrine• Transitory rarely lasting for more than a minute• Stop treatment• Place patient in most comfortable position• Monitor vital signs• Consider administrating oxygen• Allow time for the patient to recover

Epinephrine • Avoided in patients with history of stroke or heart

disease• Uterine contraction in pregnant female• Drug interactions : cocaine, MAO inhibitor• Management : ABC, activate EMS,administer oxygen

mask 10-15 l/minute• Start IV saline• Administer anticonvulsant versed (midazolam) 2 mg

then 1 mg/min• Vital signs• Recovery and discharge patient

Thank you