A Seminar on

Management of Medical Emergencies in Dental Practice

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What is an Emergency Situation ??

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)
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Clinical Presentation of Emergencies

Sudden loss of consciousness Chest pain & dyspnea Convulsions (fits)

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Basic Emergency Procedures

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APPROACH
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)
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Collapse
Vaso-vagal syncope Acute Hypoglycaemia

Anaphylactic shock
Steroid crisis Myocardial Infarction Cardiac Arrest CVA

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Acute Chest Pain or Difficulty of Breathing

Angina Myocardial Infarction

Asthma
Anaphylactic Shock

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Convulsions
Epilepsy Any other cause of loss of consciousness

including fainting

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FAINTING Predisposing factors:

Stress Conditions
Anxiety
Pain Injections

Fatigue
Hunger

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Pathophysiology
Stress

Release of catecholamines
Changes in tissue blood perfusion; decreased peripheral vascular resistance, increased blood flow to tissues leads to pooling of blood in tissue circulatory volume cerebral blood flow syncope

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Mechanism

Premonitory dizziness, weakness & nausea Pale, cold moist skin Pulse initially slow & weak, becoming full &

bounding
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Management
Lay flat & lift legs

Loosen tight clothing around neck

Give sweetened drink on regaining

consciousness Prolonged faint, Atropine 600 mcg/ml slow IV (1 ml only)

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Prevention
Good history Reassurance General Anxiety (Stress) Reduction Protocol Well fed prior to treatment Glucose drink 10 mg Temazepam nocte (prior to appt) & 1

hour before treatment Delay the procedure

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Anaphylactic Reaction

Drugs e.g. penicillin Insect stings Foods, nuts, shellfish, materials Quicker onset the more severe the reaction Widespread vasodilatation & increase in capillary permeability, potentially fatal hypotension

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Type

Hypersensitivity

Immediate IgE mediated Anaphylaxis Urticaria Angio-oedema Allergic Asthma Rhinitis

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Adverse Reactions

Hypersensitivity

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Angio-oedema

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Anaphylaxis
Signs & Symptoms variable Rapid weak or impalpable pulse Facial flushing, itching, tingling, cold extremities Bronchospasm (wheezing) Loss of consciousness Pallor going on to cyanosis Cold, clammy skin Facial oedema & sometimes urticaria Deep fall in BP
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Management of Anaphylaxis
Lay flat with raised legs Give Adrenaline (1:1000) 0.3-0.5 ml SC or IM Hydrocortisone 200 mg i.v. Chlorpheniramine 10-20 mg slow i.v. Give oxygen 6L/min & assisted ventilation Consider Cricothyrotomy if NO quick

improvement Call an ambulance

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Acute Hypoglycaemia
CAUSES:
Overdose of insulin Prevented from eating

MANAGEMENT:
Glucose tablets/powder

If unconscious give

at expected time

50ml 50% glucose IV SC glucagon 1mg

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The Diabetic Patient

Hypoglycaemia
Rapid onset Irritability Moist skin Pulse full & rapid More common Less Severe Easy to be managed

Hyperglycaemia
Slow onset Drowsiness/disorientation Dry skin & mouth Pulse slow & weak Rare More Severe Difficult to be managed

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THYROID CRISIS (STORM)

Sudden, Severe Exacerbation of Hyperthyroidism

Precipitating Factors:

Infection Surgery Trauma Pregnancy Other Physiologic or Emotional Stress

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Management
Manifestations: Hyperpyrexia (Fever) Tachycardia Agitation Palpitation Nausia, Vomiting Abdominal pain Loss of Consciousness (Partial or Complete)
Management: Terminate all dental ttt Summon medical assist Administer O2 Monitor VS Initiate BLS, if necessary Start IV line & Fluids Transport to ER Care

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STEROID CRISIS Circulatory Collapse

The Pt Problem
Adrenocortical Insufficiency: Primary (Addison`s Disease); Rare Secondary (Exogenous ttt); more common (20 mg cortisol daily/2weeks/year)

CAUSES: Stress Conditions

SIGNS & SYMPTOMS

GA Surgical/Other trauma Infection Other stress

Pallor Weakness Nausia Rapid, weak or impalpable pulse Loss of consciousness Rapidly falling BP
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Steroid Crisis Management

Lay flat and raise legs Hydrocortisone 200mg i.v. Give oxygen Monitor VS Start BLS if necessary Consider other possible reasons for loss of

consciousness Ambulance & transfer to hospital

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ASTHMA Causes
Anxiety Infection or exposure to

specific allergen Loss or forgetting to bring Salbutamol inhaler

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Asthma
Signs & Symptoms
Breathlessness Expiratory wheezing may be

disguised as shallow breathing Rapid pulse over 110 Accessory muscles of respiration brought into use Cyanosis of mucous membrane & nail beds Mental confusion
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Asthma
Management
Reassure the patient DO NOT lay the patient flat Give the anti asthmatic drug

normally used Give oxygen Give Adrenaline Hydrocortisone 200 mg i.v. Monitor VS If no response to Salbutamol 500 mcg i.m/s.c., CALL AN AMBULANCE
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Angina
Acute chest pain which may radiate to left arm or shoulder

Relieved by anti anginal drug e.g. GTN 0.5mg sublingually

Aspirin 300mg

If symptoms do not resolve rapidly with administration of GTN, consider it likely that the patient has suffered an MI

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Myocardial Infarction
Severe, crushing retrosternal pain Feeling of impending death Weak or irregular pulse

Pain may radiate to left shoulder, arm or jaw

Shock, loss of

consciousness Vomiting
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Myocardial Infarction
Place patient in a comfortable position

allowing easy breathing Send for an ambulance Give 50/50 Nitrous Oxide/Oxygen or Oxygen only Aspirin 300mg Good pain control Constant reassurance
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Cardiac Arrest Causes

Myocardial Infarction Hypoxia

Anaesthetic overdose
Anaphylaxis Severe hypotension

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CARDIAC ARREST
Signs, Symptoms & Management

Loss of consciousness Absence of arterial pulse SUMMON HELP Patient on flat, firm surface CLEAR AIRWAY (keep patent) Start CPR Defibrillation Transfer patient to hospital

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STROKE (CVA)
Severe Headache Weakness or Paralysis of arms or legs

of one side Unilateral Facial muscle Paralysis Difficulty or inability to Speak Partial or Total Loss of consciousness Patient is very anxious, needs reassurance and transfer to hospital immediately, BLS, Supine Position BUT Head slightly Elevated

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CONVULSIONS (Epilepsy)
Grand mal, Petit mal (blank stare)
Predisposing factors: Anxiety Hunger Menstruation Alcohol External stimuli, flashing lights etc Non compliance with medications

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Convulsions
Signs & Symptoms (Grand mal)
Warning cry Immediate loss of consciousness Rigid (tonic phase)

Widespread jerking (clonic phase)

Vomiting Flaccid after a few minutes Consciousness is regained after a variable period Patient may remain confused

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Convulsions
Management

Prevent patients from damaging themselves Place in Supine position Maintain patent airway No medications, await recovery Recovery position after fits have ceased Suctioning & Monitor VS Oxygen Reassure on recovery After fully recovered requires an escort home
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Status Epilepticus
Continuous or repeated convulsions for 15

minutes (patient can have severe anoxia) Give 10mg Midazolam IV repeat if no recovery within 10 minutes Maintain airway & give oxygen Call an ambulance, transfer to hospital

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The Recovery Position

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EMERGENCY KIT
Telephone Oxygen cylinder Disposable needles (23g) Tourniquet

Laerdal pocket

Cannulae (20g)
Portable suction

mask/Ambubag for hand ventilation Disposable airway (Sizes1-4) Guedel Disposable syringes (2,5,50 ml)

equipment Sphygnomanometer/Aut omatic BP machine Pulse oximeter

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DRUGS

Adrenaline 1:1000, 0.5 ml ampoules Glyceryl trinitrate 500 mcg spray Aspirin 300 mg Hydrocortisone 100mg vials Chlorpheniramine 10 mg Salbutamol 100 mcg (metered inhaler) Morphine sulphate tablets 10 mg Midazolam 10 mg Glucagon 1 mg ampoules Glucose powder or dextrose injection 50%
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Be Prepared
Adequate training Protocols

Medical history
Prevention Checks& Updating

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Reference
Medical emergency in dental office DCNA july

1995 by JEFFERY D BENNETT Medical emergency in dental office : Malamed 6th edition Text book of oral surgery by Bala JI.

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