ภาวะฉุกเฉินทางการ แพทย์ (Medical Emergencies) ใน...

ภาวะฉุ�กเฉุนทางการ แพทย์� (Medical

Emergencies) ในคลินกท�นตกรรม

• การป้�องก�น(Prevention)• การจั�ดการ(Management)

• Emergencies in dental practice can occur to any person, any time.

• How to manage, it is the most difficult thing at time occurred.

• The majority emergency is syncope.

– allergic reaction– angina pectoris– postural

hypotension– seizures– asthmatic attack– hyperventilation– hypoglycemia

• anaphylactic reaction• cerebrovascular

accident• adrenal insufficiency• thyroid storm• etc

Others

Composition of consciousness– Brain– O2

– Glucose

– Effective hemodynamic

Fact … of human brain

• Uses O2

20approx. % of tot al O2

• Uses glucose approx. 65% o f total glucose

• Uses approx. 20% of total ci / (750 ..)

Balance mechanism of :

•Hemodynamic•Respiration•Metabolism•Neurologic

Caused from impair……..– Hemodynamic– Respiration– Metabolism– Neurologic

How to avoid these

complications?•Prevention is the best •Good history taking•Good preoperative preparation

•Good operative controls

Possible causes of unconsciousness in the dental

office• Vasodepressor

syncope• Drug administration

/ingestion• Orthostatic

hypotension• Epilepsy• Hypoglycemic reaction• Acute adrenal

insufficiency

• Acute allergicreaction

• Acute myocardialinfarction

• Cerebrovascularaccident

• Hyperglycemicreaction

• Hyperventilationsyndrome

Alteration of consciousness

• Cerebrovascular accident (CVA)• Seizures• Hypoglycemia / Hyperglycemia• Adrenal insufficiency• Thyroid storm• Hyperventilation• Drug overdose

Syncope is the most common occurred.

Factors influence

•Stress and anxiety

•Health status•Drugs

How syncope occur?

In normal : circulation compensation mechanism play role in correction of deficiency O2 supply to the brain.

In syncope : circulation compensation mechanism fail to increase O2 need from the brain

How syncope occur?

Early :Feeling of warmthLoss of color : pale or ashen=gray skin tone

Heavy perspirationComplaints of feeling “bad” of “faint”

NauseaBlood pressure approximately baseline

Rapid heart rate

Signs for syncope

Signs for syncope Late :

– Pupillary dilation– Yawning– Hyperpnea– Cold hands and feet– Hypotension– Bradycardia– Dizziness– Loss of consciousness

Critical consideration•Timing of detection and

correction•Maintain O2 level to the

brain : Airway, Breathing, Circulation (ABC - Basic life support)

Orthostatic hypotension

• Failure of the baroreceptor reflex

• Loss of compensate mechanism

• Reflex bradycardia

• Loss of consciousness

Dr ugs pr oduci ng or t host at i c hypot ensi on

Category Generic name Proprietary name

Antihypertensives Guanethidine I smelin

Phenothiazines ChlorpromazineThioridazine

ThorazineMellaril

Tricyclicantidepressants

DoxepinAmitriptylineI mipramine

SinequanElavilTof ranilPresamine

Narcotics MeperidineMorphine

DemerolMorphine

Antiparkinson drugs Levodopa (L-dopa) DoparLarodopa

UnconsciousnessAssessment : Check for Breathing

–Look the chest to rise and fall–Listen for air escaping during exhalation

–Feel for the flow of air

Unconsciousness : no response to stimuli

P - position : SUPINE

Call for help : EMS activationA, B = Airway (head

tilt - chin lift) Artificial Assisted Breathing (if

no self respiration)

C = check circulation

Carotid pulse present

Carotid pulse absentCheck

medical history Vital signs

Activate EMS

Recovery

unrecovery Initiate

CPR Immedi

ate transportation

Vasodep ressor

syncope

Ortho static

hypotension

Sequence of BCLS•Assessment•EMS Activation•ABCs of CPR•D of Defibrillation

ABCs of CPR•Airway•Breathing•Circulation

Airway•Position the victim•Rescuer position•Open the Airway

–Head Tilt - Chin Lift Maneuver– Jaw Thrust Maneuver–Recommendations for Opening the Airway

Classification of causes of unconsciousness by

mechanismMechanismInadequate delivery

of blood or oxygen to the brain

Clinical example Acute adrenal

insufficiency Orthostatic

hypotension Vasodepressor

syncope

MechanismSystemic or local

metabolic deficiencies

Clinical example Acute allergic reaction

Drug ingestion andadminstration

Nitrites and nitratesDiuretics

-Sedatives narcotics Local anesthetics

HyperglycemiaHyperventilationHypoglycemia

Classification of causes of unconsciousness by

mechanism

MechanismDirect or reflex

effects on nervous system

Psychic mechanisms

Clinical example Cerebrovascular

accident Convulsive episodes

EmotionaldisturbancesHyperventilation

Vasodepressor syncope

Classification of causes of unconsciousness by

mechanism

Causes of chest pain

Cardiac related

• Angina pectoris

• Myocardial infarction

- Non cardiac related• Muscle strain• Pericarditis• Esophagitis• Hiatal hernia• Pulmonary embolism• Dissecting aortic

aneurysm• Acute indigestion• Intestinal “gas”

Chest pain is one of the major clinical clues to the presence of significant heart disease.

Definition of Terms“Atherosclerosis” is a special typ

e of thickening and hardening of - medium sized and large arterie

s because of deposits of a fatty substance.

• is an ongoing process• is a reactive biologic response of art

eries to the forces being generated by the flow of blood.

Atherosclerosis is the major factor un

derlying all forms c ardiovascular disea

se.

Normal structure

Development ofatherosclerosis

Proliferativ e change

Development ofatherosclerosis

Lipid deposition

The development of ACS

Early plaque formation

Significant plaque formation

Plaque rupture

Thrombus

Coronary arterydisease is the prese

nce of atherosclerosi s in the coronary art

eries.• Angina pectoris• Myocardial infarction

Angina is a transient discomfort (usually less than 15 minutes) due to a temporary lack of adequate blood supply to the heart muscle.

Myocardial infarction is defined as death of heart muscle (myocardium) as the result of prolonged inadequate blood flow and oxygen delivery.

Acute coronary syndromes encompasses symptomatic condition resulting in an inadequate blood supply to the heart; including unstable angina and AMI.

AMI (heart attack) is defined as death of heart tissue due to blockage of a co

ronary artery caus ed by atherosclero sis and thrombus f

ormation.

Unstable angina•Angina that is continuing, prolonged or occurring at rest.

•Represents a syndrome that lies between angina pectoris and AMI.

Angina pectoris --------------> AMI

Unstable

Angina

Risk factors : Heart attack•Risk factors that cannot

be changedAgeHeredityGenderRace

• Risk factors that can be changed

Cigarette smoking

High blood pressure

High blood cholesterol level

Physical inactivity

DiabetesObesityExcessive stress

Diagnosis Electrocardiogram

(EKG) Exercise stress test

Echocardiogram Coronary angiography

Treatment 1. Coronary artery bypass graft

sssssss () 2. Medical therapy 3. Percutaneous Transluminal Cossssss sssssssssss (PTCA)

หร�อ Percutaneous Coronary Intervention (PCI)

Drugs and bleeding in patient with CAD•Aspi r i n•Plavix•Ti cl i d•Coumadin

Angina pectoris•Potential problem related to dental care1. Stress and anxiety related to dental visit may precipitate angina attack

2. Myocardial infarction3. Sudden death

Angina pectoris

•Prevention of complication1. Detection of patient2. Referral of patient for medical evaluation and treatment

• Prevention of complication 3. Known case with medical treat

s sss sss ssssss–ssssss sssssssss ssssssss

•Premedication• Open and honest communication• Morning appointments• Short appointments• - Nitrous oxide oxygen

–sssss sssssssss ss sssss ss sssssssssss

Emergency action plan for a person with signals of heart attackUnknown case of

CAD

Recognize the signals of a heart attack

Stop activity and sit or lie down

Wait about 5 minutes to see if the symptom go away. If the pain

persists :

Known case of CAD

Recognize the signals of heart

attack

Stop activity and sit or lie down

Take 1 nitroglycerin tablet at a time at 3

- to 5 minutes intervals to

maximum total dose of 3 tablets. If

pain persists.

Transport patient to hospital

• Potential problem related to dental care1. Cardiac arrest2. Myocardial infarction3. Angina pectoris4. Congestive heart failure5. Bleeding tendency secondary to anticoagulant

• Prevention of complication

1. No routine dental care until at least 6 months after infarction

2. Medical consultation–Current status–Medication used

3. Stress reduction protocol–Premedication– Open and honest communication– Morning appointment– Short appointment– - Nitrous oxide oxygen

4. Avoid excessive amounts of essssssssss 5. Check PT s sss(cation)

Management of Acute Myocardial Infarction

Step 1. DiagnosisAdminister nitroglycerin 2. Initiate BLS 3. Summon medical assistance 4. Administer oxygen and monitor vital signs 5. Relive pain Morphine Nitrous oxide - oxygen 6. Transport patient to hospital

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Medical Problem List

1 . Cor onar y ar t er y di sease : - doubl e vessel

Status: post PCI พ.ค . + ม�.ค . 4 6at present : asymptomatic

2. DM : controlled3. HT : controlled

4. Ol d CVA : Left hemiparesis 5

yrsago at pr es ent: compl et er ecover y

5 . Mild renali nsuffi ci ency 6. Mild late onsetast hma

Current medication 1. Aspent gr. V 1 1x orally

. 2. Plavix 1 1x orally pc.

3. Plendil 1 2x orally pc. 4 . Minidiab 1 1x orally pc.

5. Bestatin 1 1x orally pc. 6 . Singvalac 1 1x hs.