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MedicalEmergencies
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Basic Principles of
Medical EmergencyManagement
PREVENTION is the mostimportant phase of treatingmedical emergencies, however
despite all efforts at prevention,EMERGENCIES will likely tohappen.
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THREE STEPS TO PREVENTMEDICAL EMERGENCIES IN THE
DENTAL CLINIC:
1. MEDICAL HISTORYA. Are there any recent changes to health?
B. Is the px under the care of a physician?C. Has the px had any serious illness/
operation?
D. Is the px taking any drugs/medications?E. Does the px have any allergies?F. Is the px pregnant?
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G. For already diagnosed disorders mustask:1. When did the px develop the disease?2. How is the problem controlled?3. Is there anything that makes theproblem worse?4. Has the px been hospitalized for the
problem?5. Are there any restrictions on the px?
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2. PX EVALUATION
A. Record vital signsB. Complete dental examC. Visual inspection of px
Formulate your tx plan at this stage.Determine how this tx plan relates to or
is affected by the findings of the medicalhistory & evaluation. Obtain medicalconsults if needed at this point.
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3. STAFF TRAINING ANDPREPARATION
A. Training: Staff needs to haveknowledge to identify and
correctly manage eachemergencyB. Easily accessible emergency
equipment and drugsC. Coordination of office
personnel
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What is adequate preparation?
Guidelines vary, but in general, it isexpected that the dentist will beable to initiate emergency mgt. andbe capable of sustaining a victimslife through the application of BasicLife Support (BLS).
***In times of crisis, simplicity haltsconfusion.***
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BASIC PRINCIPLE OF MANAGINGALL MEDICAL EMERGENCIES
1. BLS: remember ABCs 2. Place the px supine3. Call for assistance4. Assure px if conscious5. Maintain airway6. Place px on oxygen as indicated by
nature of emergency7. Monitor vital signs8. Diagnose nature of event9. Initiate specific tx10. Document, document, document!
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STRESS REDUCTION PROTOCOLFOR THE ANXIOUS PX
1. Recognize pxs anxiety level 2. Consider using pre-medication/
sedation
3. Schedule morning appointments4. Minimize waiting time and watchappointment length
5. Make sure to use adequate paincontrol. (varies from px to px)6. Monitor vital signs
7. Medical consultation if required
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Airway ObstructionGeneral signs and symptoms
1. Gasping of breath2. Px grabs at throat3. Panic4. Suprasternal/supraclavicular
retraction
If Partial Obstruction - snoring,gurgling, wheezing, growling
If Total Obstruction - no noise
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Causes of Airway Obstruction1. Hypo-pharyngeal obstruction
(foreign bodies)
2. Blood, water, or saliva inmouth3. Bronchoconstriction4. Laryngospasm5. Tongue (most common)
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Treatment 1. Place px supine on the floor/ 15-30 0 back
in the dental chair 2. Head tilt/chin lift3. Check airway & breathing, assess cause
of obstruction
4. If cause by fluid use suction5. Consider jaw thrust6. Reassess airway and breathing
7. If not breathing attempt CPR8. Reassess airway and breathing9. If cause by foreign body use HEIMLICH
MANEUVER
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HEIMLICHMANEUVER/
ABDOMINAL THRUST/ABDOMINAL HUG
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ON ADULT
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ON A CHILD
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ON INFANT
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ON ONESELF
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CARDIOPULMONARYRESCUCITATION
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Remember the CAB of CPR
Circulation : Restore bloodcirculation with chest
compressionsAirway : Clear the airway
Breathing : Breathe for theperson
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Airway: Clear the airway -Open the person's
airway using thehead-tilt, chin-liftmaneuver. Putyour palm on theperson's foreheadand gently tilt thehead back. Thenwith the other hand, gently liftthe chin forwardto open the
airway.
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Breathing: Breathe for the person
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Rescue breathing can be mouth-to-
mouth breathing or mouth-to-nosebreathing if the mouth is seriouslyinjured or can't be opened.
With the airway open (using thehead-tilt, chin-lift maneuver), pinchthe nostrils shut for mouth-to-mouth breathing and cover theperson's mouth with yours, makinga seal.
Ci l i R bl d
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Circulation: Restore bloodcirculation with chest compressions
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Put the person on his or her back
on a firm surface.Kneel next to the person's neck andshoulders.Place the heel of one hand over thecenter of the person's chest,between the nipples. Place your other hand on top of the first hand.
Keep your elbows straight andposition your shoulders directlyabove your hands.
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Use your upper body weight (not just your arms) as you push
straight down on (compress) thechest at least 2 inches(approximately 5 cms). Push hardat a rate of about 100 compressionsa minute.If you haven't been trained in CPR,continue chest compressions until
there are signs of movement or until emergency medical personneltake over. If you have been trainedin CPR, go on to checking the
airway and rescue breathing.
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Hyperventilation
Signs and symptoms:1. dizziness2. hard to breathe3. shaking and trembling4. cold clammy hands5. tight feeling in chest, chest pain and
palpitations
6. lightheaded7. uncontrolled over breathing 25-30/min.8. increase BP and heart rate9. tingling in hands, feet and perioral areas
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Management of Hyperventilation
1. Discontinue tx and remove anyforeign objects from the pxs mouth 2. Position px upright3. Assess airway4. Reassure px and try to calm them5. Have px breath slowly and
shallowly into a paper bag or mask6-10x/min.
6.Monitor vital signs7. Determine what precipitated attack8. Dismiss px only after vitals signs
returned to normal
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Allergic Reaction
Signs and symptoms1. cutaneous rxns. urticaria,
itching2. angioedema (swelling)3. tightness in chest, sneezing4. ocular rxns. conjunctivitis,
watery-eyes
5. hypotension
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ANAPHYLAXIS severe systemic typeof allergic reaction and is a medicalemergency
Signs and symptoms:1. cardiovascular shock including pallor,
syncope, palpitations, tachycardia,hypotension, arrythmias, andconvulsions
2. respiratory symptoms include sneezing,cough, wheezing, chest tightness,
bronchospasm, laryngospasm3. skin is warm and flushed with itching,urticaria, angioedema
4. nausea, vomitting, abdominal cramps,and diarrhea also possible
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Treatment:General tx: ABCs, maintain airway,
administer oxygen, monitor vital signs,and if in shock, put px in a horizontalposition or slight Trendelenburg position(head lower than leg position)
Mild Reaction: antihistamines usuallyeffective (Benadryl 50-100mg/Cholpheniramine maleate 4-12mg PO, IVor IM), identify and remove allergen,
follow up medication every 4-6hrs.Severe Reaction: call emergency hotlineand bring the px to the nearest hospitaland observe within 24 hrs.
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Asthma Attack Signs and Symptoms:
1. suffocation2. chest pressure/tightness3. non-productive cough4. wheezes5. expiration is prolonged than
inspiration6. chest is distended7. thick stringy mucous
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Severe asthma attack includes: cyanosis of the nail beds,perspiration and flushing of theskin, px may appear confused and
agitated, use of accessory musclefor respiration (sternocleido-mastoid and shoulder/ abdominalmuscles)
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Management of an AsthmaAttack
1. discontinue dental tx2. place px in easiest position for them tobreath (usually upright with armsoutstretched)
3. Albuterol inhaler (Proventil) 2 puffsevery 2 mins.4. supplemental oxygen at 10L/min. if
available
5. monitor vital signs6. if no improvement, call emergency7. start IV, epinephrine 1:1000 -
0.3g/20mins. If available
l d f h
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Dental Tx Consideration for theAsthma Px
1. take a good medical historyprior to tx determine how oftenthe attack and what precipitates
it2. schedule morning appointments3. if px uses inhaler they should
bring it on hand during tx(consider prophylactic use prior to tx)
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Angina PectorisSigns and symptoms:
1. substernal pain from chest andradiates to any area above thediaphragm
2. vary form heavy squeezing pain to aheavy pressure on the chest
3. pain usually lasts for few mins. and
disappears with rest4. other symptoms: palpitations, faintness,
dizziness, dyspnea, digestivedisturbance
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Management of Angina Pectoris1. stop all tx2. position px upright3. call emergency4. administer oxygen if available
5. monitor and record vital signs6. administer one tablet of Nitroglycerin
sublingually7. if no relief after two mins. Repeat
Nitroglycerin (can repeat a third time if no relief but if after the 3 rd time still norelief, the px may be suffering from heartattack))
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Dental Consideration for Px withAngina history
1. tx should be oriented towardsprevention of angina attack
2. pre-medication of Nitroglycerinsublingually prior to any injectionor surgical procedures
3. administer oxygen by nasal canuladuring procedure
4. consider use of oral/IV sedation toreduce anxiety
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Heart Attack (Myocardial Infarction)
Signs and symptoms:1. preceded by angina2. heavy, squeezing, pressing or crushing
pain in nature (pain located over middle3 rd of sternum)
3. pain radiates to left arm in many casesand can also radiate to the mandible
4. not relieved by Nitroglycerin5. px express intense fear, restless6. dyspnea (shortness of breath)7. Levines sign: px clutch chest with fist
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Management of Heart Attack1. stop all tx2. clear mouth with any foreign
objects3. place px in an upright position
4. if available administer oxygen 10L-15L/min.5. call emergency, send px to hospital6. monitor and record vital signs7. give px Aspirin (325mg.) if
available8. if px loses consciousness, initiate
BLS
S
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Syncope(Fainting/Unconsciousness)
Signs and symptoms can be divided into3 categories:
1. Pre-syncope: warm feeling in face/neck,pale, sweating, feels cold, abdominaldiscomfort, dizziness, dilated pupil,yawning, fast heart rate, slight decreasein BP
2. Syncope: fainting, generalized musclerelaxation, weak pulse, twitching of hands/legs/face, eyes open
3. Post-syncope: heart rate increases, BPback to normal, mental confusion
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Management of Syncope1. stop all tx2. remove all objects inside pxs
mouth3. place px in supine position
with legs elevated and head atlevel of heart
3. establish ABC4. use Ammonia5. if unconscious for more than 1
min., call emergency
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TYPES1. Hemorrhagic loss of blood2. Respiratory insufficient breathing
3. Neurogenic interference with thesympathetic nervous
system
Shock
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4. Psychogenic thoughtpatterns in the brain
5. Cardiogenic
inadequate function of the heart
6. Septic cause bybacterial, microbial, or viral infection
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7. Anaphylactic allergicreaction (antigen-antibody rxn)
8. Metabolic diabetes,low blood sugar, insulinshock
9. Postural suddenchange of body position
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Management of Hemorrhagic ShockMechanical means1. Application of folded, sterile
gauze square compressedover the wound for 20-30min.
2. Suturing3. Electric cautery
4. Ligation of vessel
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COMMONLY USEDHEMOSTATIC DRUGS INDENTISTRY1. Monsels solution
2. Thrombin3. Tannic acid
4. Gel foam5. Oxygel6. Surgicel
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HEMOSTATIC DRUGS
1. COAGULANT - promotesblood clotting
2. ASTRINGENT - appliedtopically causing capillariesto contract
3. EPINEPHRINE - controlsminor bleeding
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Management of PosturalShock
1. Immediately reposition the px ina supine position
2. If the px is unconscious and
does not revive,tilt his head back(chin up) and check hisbreathing. If not normal, do tripleairway check
3. Slowly return the px in an uprightposition. If he feels dizzy andfaint, lower him to the supine
position at once.
f
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Management of Anaphylactic Shock 1. Anti-histamine2. Epinephrine 1:1000 in a dosage
of .5 ml subcutaneously in thearm or thigh. If severe,additional dose after 10
minutes3. Oxygen to relieve patients
distress along with anti
histamine
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Management of
Cardiogenic Shock1. Let px sit upright at a 45
degree angle2. Give oxygen and call
emergency
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Management of
Psychogenic Shock1. Lower the px to a supine
position.2. Pxs feet should be elevated
to a position higher than hishead to cause the blood toflow towards the brain(Trendelenberg position)
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3. An ampoule of spirits of ammonia may be fractured ina gauze square and waftedgently under the patientsnostrils.
4. The PR and the BP should betaken and recorded for thedentist to interpret. Usuallypx regains consciousnesswithin 1 to 2 minutes.
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EpilepsyClassification:
1. Petit mal-mild and brief in duration,few seconds
-px may seem to be staringinto space
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2. Grand mal-severe with loss of consciousness, followedby violent contraction of the muscles
-may last several minutes
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Management of Epilepsy
1. Protect the px from self injury
2. Heavily padded tonguedepressor or folded towelshould be placed betweenthe pxs teeth to preventtongue biting
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3. Attempt to maintain afree airway for the px but
do not put your fingersin the pxs mouth
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NOTE:
OVERFATIGUE ANDANXIETY TRIGGERS
SEIZURE - Epileptic pxs should
be scheduled for txearly in the day
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STROKE
also known as a cerebrovascularaccident (CVA)It is the rapid loss of brain functiondue to disturbance in the bloodsupply to the brain.This can be due to ischemia (lack of blood flow) caused by blockage(thrombosis, arterial embolism), ora hemorrhage (leakage of blood
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Signs and symptoms
Smoothing out of foreheadEyebrow droopDrooping of the corner of themouth
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Classification of stroke1. Ischemic - occur as a result of an
obstruction within a blood vesselsupplying blood to the brain. Theunderlying condition for this type of
obstruction is the development of fatty deposits lining the vessel walls.2. Hemorrhagic - It results from a
weakened vessel that ruptures andbleeds into the surrounding brain.The blood accumulates andcompresses the surrounding brain
tissue.
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Risk factors of stroke Over age 55 More common in males
African American,Hispanic or Asian/PacificIslander
A family history of stroke High blood pressure
Hi h h l t l
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High cholesterol Smoking cigarettes
Diabetes Obesity and overweight Cardiovascular disease A previous stroke or transient
ischemic attack (TIA) High levels of homocysteine (an
amino acid in blood)
Birth control use or other hormonetherapy Cocaine use Heavy use of alcohol
DENTAL MANAGEMENT OF THE
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DENTAL MANAGEMENT OF THESTROKE PATIENT
A patient with stroke in his record shall getspecial care during dental treatment:appointments shall be for choice in the
morning, shall be short and without stress.Clinical approach shall take intoconsideration in several aspects: Disabled patients shall be helped by the nurse to
sit on dental chair, their airways shall be free andthey shall be accompanied by the persons takingcare of them, especially if speech difficulties arepresent
DENTAL MANAGEMENT OF THE
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DENTAL MANAGEMENT OF THESTROKE PATIENT
Anamnesis shall be simple and optimistic, dentistshall stand in front of the patient, without mask,shall look him in the eyes, shall move slowly andquestions shall be simple and clear, for plainanswers (yes/no)
Anamnesis should reveal patients risk factors: if themedical record shows high blood pressure, cardiacdiseases, transient vascular accidents, diabetes,heavy smoking, old age, then such a patient isprone to stroke and/or myocardial infarction.
History of past strokes needs to be elicited: date,seriousness, treatment, disabilities. There aresituations when patients speech is not affected, buthe cannot realize the extent of the palsy (he is notaware of it) or situations when a patient with braininjury on his right side is neglecting his left side of
the body
DENTAL MANAGEMENT OF THE
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DENTAL MANAGEMENT OF THESTROKE PATIENT
Blood pressure and pain should bemonitored and under control duringthe entire intervention
Emergency dental treatment isallowed six months after stroke, itshould be performed carefully, byneurologists advice and someprecautions are needed, according tothe specific characters of the stroke
DENTAL MANAGEMENT OF THE
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STROKE PATIENT If needed, dental treatment produces
bleeding (teeth extraction, pulpectomy,subgingival scaling, periodontal surgery),anticoagulant systemic medication maycause serious hemorrhage, thereforeanticoagulant drugs like heparin should bestopped at least 6-12 hours beforetreatment. Six hours after bleeding, whenblood clots are built up, heparin systemictreatment can be resumed. If there is some
other anticoagulant medication involved,it should be stopped several hours or daysbefore bleeding dental treatment, afterdetermining the International ClottingRate (ICR) and decision depends onneurologists advice
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The dentist should be ready foremergency intervention in case of local hemorrhage, with haemostatic
medication and cautery, bloodpressure should be monitored andoxygen therapy device is needed in
dental office
DENTAL MANAGEMENT OF THE
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DENTAL MANAGEMENT OF THESTROKE PATIENT
The minimal amount of anestheticsolutions should be injected,concentration of added epinephrineshould be very low (1:100.000 or1:200.000). Use of gingival retractioncord soaked with epinephrine shouldbe avoided.Metronidazolum and tetracyclineshould be avoided, since they mayaffect blood clotting.If the patient shows symptoms of stroke, he should get oxygen therapyimmediately and should be referred toa hospital as soon as possible.
DENTAL MANAGEMENT OF THE
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DENTAL MANAGEMENT OF THESTROKE PATIENT
If patients show minor physicaldisabilities after stroke, they canpresent poor oral hygiene. For suchpatients, dentists will advise the useof electric toothbrushes, easier tohandle, use of dental floss, oralirrigation and prophylaxis usingchlorhexydine and fluoride.
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Patients with speech and deglutitiondisabilities due to paralysis of oro-facial
muscles, with loss of sensitivity of thetissues, with flaccid, multiple pleated andpossibly asymmetrically positionedtongue, with dysphagia, may presentaccumulation of food residues on teeth,tongue, oral mucosa. They must learn toclean their teeth and oral cavity usingonly one hand or to get/accept anotherpersons help, in order to avoid caries,periodontitis, halitosis or oral mucosadiseases.
DENTAL MANAGEMENT OF THE
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DENTAL MANAGEMENT OF THESTROKE PATIENT
Edentulous patients are advised toget fixed prosthodontic treatment,because of the difficulties of insertion and removal of removabledentures.
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