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    D R . S A A D B I N Q A S I M , B . D . S , M S C ( L O N D O N )

    R E S E A R C H S C H O L A R

    K I N G S A U D U N I V E R S I T Y

    C O L L E G E O F A P P L I E D M E D I C A L S C I E N C E S

    D E P A R T M E N T O F D E N T A L H E A L T H .

    ManagementManagementofof

    Medical EmergenciesMedical Emergenciesinin

    Dental Pr acticeDental Pr actice

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    CONTENTS

    What is an Emergency situation. Clinical presentation of emergency Basic Emergency Procedure Approach

    Collapse, Acute chest pain, Convulsion, Fainting Pain, Mechanism, Management, Prevention Anaphylactic Reaction. Diabetes, Thyroid crisis

    Asthma Angina MI, Stroke

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    Common Emergency Situations are:

    Fainting (Vasovagal Syncope )

    Diabetic Coma

    Anaphylactic Shock

    Epileptic Seizures

    Cardiovascular Collapse (CVC)

    Thyroid Crises

    Adrenal Crises

    Asthmatic Attack

    Stroke (Cerebro-vascular Accident, CVA)

    What is an Emergency Situation ??

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    Sudden loss of consciousness

    Chest pain & dyspnea Convulsions (fits)

    Clinical Presentation of Emergencies

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    Basic Em ergency Pro cedures

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    Predisposing factors

    Signs & symptoms

    Differential diagnosis

    (The Main Problem of every Systemic Condition)

    Management

    Reassess(The General Procedures of Maintaining the Pt Life; VS +

    Specific Management for each Condition)

    APPROACH

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    Vaso-vagal syncope

    Acute Hypoglycaemia

    Anaphylactic shock

    Steroid crisis

    Myocardial Infarction

    Cardiac Arrest

    CVA

    COLLAPSE

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    Angina

    Myocardial Infarction

    Asthma

    Anaphylactic Shock

    ACUTE CHEST PAIN OR DIFFICULTY OF

    BREATHING

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    EpilepsyEpilepsy

    Any other cause of loss of consciousnessAny other cause of loss of consciousness

    including faintingincluding fainting

    CONVULSIONSCONVULSIONS

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    AnxietyAnxiety

    PainPain

    InjectionsInjections

    FatigueFatigue

    HungerHunger

    FAINTINGFAINTINGPredisposingPredisposing factors:factors:

    Str ess ConditionsStr ess Conditions

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    PremonitoryPrem onitory dizziness, weakn ess & nauseadizziness, weakn ess & nausea

    Pale, cold m oist skinPale, cold m oist skin

    Pulse initially slow & w eak, becom ing full &Pulse initially slow & w eak, becom ing full &boundingbounding

    MechanismMechanism

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    Lay flat & liftLay flat & lift legslegs

    Loosen tight clothing aro und neckLoosen tight clothing aro und neck

    Give sw eetened drink on regainingGive sw eetened drink on regaining

    consciousnessconsciousness Pro longed faint, Atro pine 600 m cg/m l slowPro longed faint, Atro pine 600 m cg/m l slow

    IVIV (1(1 ml only)m l only)

    ManagementManagement

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    Good historyGood history

    ReassuranceReassurance

    Gener al Anxiety (Stress) ReductionGener al Anxiety (Stress) ReductionProtocolProtocol

    W ell fed prior to treatm entW ell fed prior to treatm ent

    Glucose dr inkGlucose dr ink

    10 m g10 m g Tem azepamTemazepam no ctenocte (prior to appt) & 1(prior to appt) & 1hour before treatmenthour before treatment

    Delay the pr ocedur eDelay the pr ocedur e

    PreventionPrevention

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    Dru gs e.g. penicillinDru gs e.g. penicillin

    Insect stingsInsect stings

    Foods, nuts, shellfish, m aterialsFoods, nuts, shellfish, m aterials Quicker onset the m ore sever e the reactionQuicker onset the m ore sever e the reaction

    W idespread vasodilatation & increase inW idespread vasodilatation & increase incapillar y per m eability, potentially fatalcapillar y per m eability, potentially fatal

    hypotensionhypotension

    Anaphylactic ReactionAnaphylactic Reaction

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    Type I HypersensitivityType I Hypersensitivity

    Immediate

    IgE mediated Anaphylaxis Urticaria Angio-oedema

    Allergic Asthma Rhinitis

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    Adverse ReactionsAdverse Reactions

    HypersensitivityHypersensitivity

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    AngioAngio--oedemaoedema

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    Signs & Sym ptoms var iableSigns & Sym ptoms var iable

    Rapid weak o r im palpable pulseRapid weak o r im palpable pulse

    Facial flushing, itching, tingling, coldFacial flushing, itching, tingling, cold

    extremitiesextremities BronchospasmBr onchospasm (wh eezing)(wheezing)

    Loss of con sciousnessLoss of con sciousness

    Pallor going on to cyanosisPallor going on to cyanosis

    Cold, clam m y skinCold, clam m y skin

    Facial oedem a & som etim esFacial oedema & som etim es urticariaurticaria

    Deep fall in BPDeep fall in BP

    AnaphylaxisAnaphylaxis

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    Lay flat with r aised legsLay flat with r aised legs

    Give Adre naline (1:1000)Give Adre naline (1:1000) 0.30.3--0.5 ml SC or IM0.5 ml SC or IM

    Hydrocor tisone 200 m gHydrocor tisone 200 m g i.vi.v.. ChlorpheniramineChlorpheniram ine 1010--20 m g slow20 mg slow i.vi.v..

    GiveGive oxygen 6L/m inoxygen 6L/m in & assisted& assisted ventilationventilation

    ConsiderConsider Cricothyrotom yCricothyrotomy if NO quickif NO quickimprovementimprovement

    Call an am bulanceCall an am bulance

    Management of Anaph ylaxisManagement of Anaph ylaxis

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    Acute Hypoglycaem iaAcute Hypoglycaem ia

    CAUSES:CAUSES:

    Overdose of insulinOverdose of insulin

    PreventedPrevented fromfrom eatingeating

    at expected tim eat expected tim e

    MANAGEMENT:MANAGEMENT:

    GlucoseGlucosetablets/powdertablets/powder

    If unconscious giveIf unconscious give50ml 50% glucose IV50ml 50% glucose IV

    SCSC glucagonglucagon 1m g1m g

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    The Diabetic PatientThe Diabetic Patient

    HypoglycaemiaHypoglycaemia

    Rapid onsetRapid onset

    IrritabilityIrritability

    Moist skinMoist skin

    Pulse full &Pulse full & rapidrapid

    More comm onMore comm on

    Less SevereLess Severe

    Easy to be m anagedEasy to be m anaged

    HyperglycaemiaHyperglycaemia

    Slow onsetSlow onset

    Drowsiness/disorientatiDrowsiness/disorientationon

    Dry skin & m outhDry skin & m outh

    Pulse slow &Pulse slow & weakweak

    RareRareM ore Sever eM ore Sever e

    Difficult to be managedDifficult to be managed

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    Precipita ting Factors:Precipita ting Factors:

    InfectionInfection SurgerySurgery

    TraumaTrauma

    PregnancyPregnancy

    Other Physiologic or Emotional StressOther Physiologic or Emotional Stress

    THYROID CRISIS (STORM)THYROID CRISIS (STORM)

    Sudden, Severe Exacerbation of HyperthyroidismSudden, Severe Exacerbation of Hyperthyroidism

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    Manifestations:Manifestations:

    HyperpyrexiaHyperpyrexia(Fever)(Fever)

    TachycardiaTachycardia AgitationAgitation

    PalpitationPalpitation

    NausiaNausia, Vom iting, Vom iting

    Abdom inal painAbdom inal pain Loss ofLoss of

    ConsciousnessConsciousness(Partial or(Partial orComplete)Complete)

    Management

    Management:Management:

    Term inate all dentalTerm inate all dentaltttttt

    Summ on m edicalSumm on m edicalassistassist

    Adm inister O2Adm inister O2

    Monitor VSMonitor VS

    Initiate BLS, ifInitiate BLS, ifnecessarynecessary

    Start IV line & FluidsStart IV line & Fluids

    Transpo rt to ER CareTranspo rt to ER Care

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    STEROID CRISISSTEROID CRISISCirculatoryCirculator y CollapseCollapse

    The Pt ProblemThe Pt ProblemAdrenocorticalAdren ocor tical Insufficiency: Prim ary (Insufficiency: Prim ary (Addison`sAddison`s Disease); RareDisease); Rare

    Secondary (ExogenousSeconda ry (Exogenous tttttt); more com mo n (20 mg); mo re com mo n (20 mg cortisolcortisoldaily/2weeks/year)daily/2weeks/year)

    CAUSES: StressStressConditionsConditions

    GA

    Surgical/Othertrauma

    Infection

    Other stress

    SIGNS & SYMPTOMS Pallor

    Weakness

    Nausia

    Rapid, weak orimpa lpable pulse

    Loss of consciousness

    Rapidly falling B P

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    Lay flat and ra ise legs

    Hydr ocor tisone 200m g i.v.

    Give oxygen Monitor VS

    Start BLS if necessary

    Consider other possible reaso ns for loss of

    consciousness Am bulance & transfer to hospital

    Steroid Cr isis Managem entSteroid Cr isis Managem ent

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    Anxiety

    Infection or exposure to

    specific aller gen Loss or forgetting to br ing

    Salbutam ol inhaler

    ASTHMAASTHMA

    CausesCauses

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    BreathlessnessBreathlessness

    Expiratory w heezing may beExpiratory w heezing may bedisguised as sh allow breathingdisguised as sh allow breathing

    Rapid pulse over 110Rapid pulse over 110

    Accessory mu scles ofAccessory mu scles ofrespiration brou ght intorespiration br ought into useuse

    Cyanosis of m ucousCyanosis of m ucousm embr ane & nail bedsm embr ane & nail beds

    Mental confusionMental confusion

    AsthmaAsthma

    Signs & Symptom sSigns & Symptom s

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    Reassur e the patient

    DO NOT lay the patientflat

    Give the anti asthm aticdrug nor m ally used

    Give oxygen

    Give Adren aline

    Hydrocor tisone 200 m gi.v.

    Monitor VS

    If no re sponse to

    Salbutam ol 500 m cg

    AsthmaAsthma

    ManagementManagement

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    Acute chest pain w hich mayradiate to left arm orshoulder

    Relieved by anti anginaldrug e.g. GTN 0.5m gsublingually

    Aspirin 300m g

    If sym ptom s do not re solverapidly w ith adm inistrationof GTN, consider it likelythat the patient has suffered

    an MI

    AnginaAngina

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    Severe, crushing retro-sternal pain

    Feeling of im pendingdeath

    W eak or irr egular pulse

    Pain m ay radiate to leftshoulder, arm or jaw

    Shock, loss ofconsciousness

    Vomiting

    MyocardialMyocar dial InfarctionInfarction

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    Place patient in a com fortable positionallow ing easy breathing

    Send for an ambulance

    Give 50/50 Nitrou s Oxide/Oxygen orOxygen only

    Aspirin 300m g

    Good pain control

    Constant reassura nce

    MyocardialMyocar dial InfarctionInfarction

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    Myocar dial InfarctionMyocar dial Infarction

    HypoxiaHypoxia

    Anaesthetic overdo seAnaesthetic overdo se AnaphylaxisAnaphylaxis

    Severe h ypotensionSevere h ypotension

    Cardiac ArrestCardiac Arrest

    CausesCauses

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    Loss of con sciousness

    Absence of ar terial pulse

    SUM M ON H ELP Patient on flat, firm sur face

    CLEAR AIRW AY (keep patent)

    Start CPR

    Defibrillation

    Transfer patient to h ospital

    CARDIAC ARRESTCARDIAC ARREST

    Signs, Sym ptom s & Managem entSigns, Sym ptom s & Managem ent

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    Severe HeadacheSevere Headache

    WeaknessW eakness or Paralysis ofor Par alysis of arm sarmsoror legs of one sidelegs of one side

    Unilateral Facial m uscleUnilateral Facial m uscleParalysisParalysis

    Difficulty or inability to SpeakDifficulty or inability to Speak

    Par tial or Total Loss ofPar tial or Total Loss of

    consciousnessconsciousness PatientPatient is veryis very anxious, n eedsanxious, needs

    reassura nce and transfer toreassura nce and transfer tohospitalhospital imm ediately, BLS,imm ediately, BLS,Supine Po sitionSupine Po sition BUT H eadBUT H ead

    STROKE (CVASTROKE (CVA))

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    Predisposing factors:Predisposing factors:

    AnxietyAnxiety

    HungerHunger MenstruationMenstruation

    AlcoholAlcohol

    Exter nal stimuli, flashing lightsExter nal stimuli, flashing lightsetcetc

    Non com pliance w ithNon com pliance w ithmedicationsmedications

    CONVULSIONS (Epilepsy)CONVULSIONS (Epilepsy)

    Gran d m al, Petit m al (blank stare)Gran d m al, Petit m al (blank stare)

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    W arning cryW arning cry

    Imm ediate loss of consciousnessImm ediate loss of consciousness

    Rigid (tonic phase )Rigid (tonic phase ) W idespread jerking (W idespread jerking (clonicclonic pha se)phase)

    VomitingVomiting

    Flaccid after a few m inutesFlaccid after a few m inutes

    Consciousn ess is regained a fter a variableConsciousn ess is regained a fter a variableperiodperiod

    Patient may rem ain confusedPatient may rem ain confused

    ConvulsionsConvulsions

    Signs &Signs & Sym ptom s (Gran d m al)Sym ptom s (Grand m al)

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    PreventPrevent patients from dam agingpatients from dam agingthemselvesthemselves

    Place in Supine positionPlace in Supine position

    MaintainMaintain patentpatent airwa yairway

    No m edications, aw aitNo m edications, aw ait recoveryrecovery

    Recover y position after fits ha ve ceasedRecover y position after fits ha ve ceased

    Suctioning & Monitor VSSuctioning & Monitor VS OxygenOxygen

    Reassure on recoveryReassure on recovery

    After fully recovered requires an e scortAfter fully recovered requires an e scort

    ConvulsionsConvulsions

    ManagementManagement

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    Continuous or repeated convulsions for 15m inutes (patient can have severe ano xia)

    Give 10mg Midazolam IV r epeat if no

    recover y within 10 m inutes Maintain airw ay & give oxygen

    Call an am bulance, tran sfer to h ospital

    StatusStatus EpilepticusEpilepticus

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    The Recovery Position

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    EM ERGENCY KI TEM ERGENCY KI T

    TelephoneTelephone

    Oxygen cylinderOxygen cylinder

    LaerdalLaerdal pocketpocket

    mask/mask/AmbubagAm bubag forforhan d ventilationhan d ventilation

    Disposable airwa yDisposable airwa y(Sizes1(Sizes1--4)4) GuedelGuedel

    Disposable syringesDisposable syringes(2,5,50 m l)(2,5,50 m l)

    Disposable needles(23g)

    Tourniquet

    Cann ulae (20g) Por table suction

    equipment

    Sphygnomanometer/Autom atic BP m achine

    Pulse oximeter

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    Adren aline 1:1000, 0.5 m l am poules

    Glyceryl trinitra te 500 m cg spray

    Aspirin 300 m g

    Hydr ocor tisone 100m g vials

    Chlorpheniram ine 10 m g

    Salbutam ol 100 m cg (m etered inhaler)

    Mor phine sulphate tablets 10 m g

    Midazolam 10 m g

    Glucagon 1 mg am poules

    Glucose powd er or dextrose injection

    50%

    DRUGSDRUGS

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    Adequate trainingAdequate training

    ProtocolsProtocols

    Medical histor yMedical histor y PreventionPrevention

    Checks& UpdatingChecks& Updating

    Be PreparedBe Prepared