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GOOD MORNING
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Management of medical emergencies in dental
office
Presented by: Dr. MANU MATHEW
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INTRODUCTION
• They do happen in dental office• Can be – patient
Doctor Staff By stander
• McCarthy- all but 10% can be prevented
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CLASSIFICATION
• Systems oriented -infectious -respiratory system
-cardiovascular system -nervous system -git and liver
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• Cardio vascular and non cardio vascular - stress related
- non stress related• Based on clinical signs and symptoms -unconciousness
-respiratory distress -altered conciousness -seizures -drug related emergencies -chest pain -sudden cardiac arrest
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PREVENTION• Goldberger – when you prepare for an
emergency, the emergency ceases to exist• Physical evaluation -physically
-psychologically -treatment modifications -psychosedation- appropriate technique &drug
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PHYSICAL EVALUATION
• Medical History• Physical Examination• Vital Signs• Dialogue History• Anxiety recognition• Determination of Medical Risk
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MEDICAL HISTORY
• Questionnaire divided into-signs &symptoms-diagnosed diseases-medical treatments
• Update• Medication• Medical consultation
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PHYSICAL EXAMINATION
• Visual inspection of patients• Auscultation,monitoring & lab tests • Referral to physician• Monitoring Vital signs
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VITAL SIGNS
• Blood pressure• Pulse rate• Respiratory rate• Temperature• Height• Weight
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DIALOGUE HISTORY
• Check accuracy of medical history• Recognize anxiety
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ANXIETY RECOGNITION
• Medical history questionnaire• Dental anxiety questionnaire- Dr.Norman
Corah• Observation
-excessive bp and heart rate-trembling-excessive sweating-dilated pupils
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DETERMINATION OF MEDICAL RISK
• Ability of patient to safely tolerate dental treatment.
• Does patient represent increased medical risk?
• Can patient be managed in the dental office?
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ASA PHYSICAL STATUS CLASSIFICATION SYSTEM
• American society of anaesthetologists• 1962• 5 categories
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ASA I
• A patient without systemic disease• A normal healthy patient• Can tolerate stress involved in dental
treatment• No added risk of serious complications• Treatment modification usually not
necessary
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ASA II
A patient with mild systemic disease like-Well-controlled diabetic-Well-controlled asthma-ASA I with anxiety• Represent minimal risk during dental treatment• Routine dental treatment with minor
modifications-Short early appointments-Antibiotic prophylaxis
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ASA III
A patient with severe systemic disease that limits activity but is not incapacitating like - a stable angina, 6 mos. Post – MI,6 mos. Post – CVA, COPD• Elective Dental Treatment is not contraindicated• Treatment Modification is Required
- Reduce Stress- Sedation- Short Appointments
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ASA IV
• A patient with incapacitating systemic disease that is a constant threat to life like unstable angina pectoris, MI&CVA(within 6 mos.),BP>200mmHg or 115mmHg
• Elective dental care should be postponed• Emergency dental care only
–Rx only to control pain and infection–When immediate intervention is needed
should be done in a hospital
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ASA V
• A moribund patient not expected to survive more than 24 hrs with or without surgery
• They may be referred to as DNAR (Do Not Attempt Resuscitation) or no code patients
• It includes end stage of renal diseases, cancer,hepatic disease
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• ASA E• Emergency operation of any variety, withE
preceding the number to indicate the patient’s physical status like ASA E- III
• ASA VI -recently added• Defined as a declared brain-dead patient
whose organs are being removed for donor purposes
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STRESS REDUCTION PROTOCOL
• Recognition of medical risk & anxiety• Medical consultation• Premedication – 1 hr prior to procedure• Appointment scheduling• Minimized waiting time• Vital signs- pre & post op• Psycho sedation during treatment
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• Adequate pain control during the treatment• Duration of dental treatment• Post operative control of pain and anxiety
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PREPARATION
• Team Effort• BLS for all office personnel• Emergency drills• Emergency phone numbers • Emergency equipment
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EMERGENCY DRUG KITSCRITICAL DRUGS• Adrenaline (Epinephrine)
1 in 1000• Antihistamines• Oxygen• Aspirin• Anti hypoglycemic- sugar• Vasodilator (GTN
tabs/sprays)• Bronchodilator
(Salbutamol inhaler)
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ABC OF EMERGENCY
• A- AIRWAY• B- BREATHING• C- CIRCULATION
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AIRWAY
• Finger sweep• Suction• Head tilt/Chin lift
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BREATHING
• Look- listen- and- feeltechnique
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CIRCULATION
• Monitoring the BP and heart rate• In non emergency situations -brachial
-radial• In emergency
- Carotid artery in the neck
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CPR
• 30 chest compressions to 2 ventillations in adult
• For chest compression- patient should lay on a flat firm surface
- skin must be visible - place heel of one hand over centre of
victim’s chest - put the heel of other hand on top of first
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-straighten your arms and position your shoulders directly over the hands
- push hard and fast upto 1.5 to 2 inches with each compression
- at the end of each compression allow chest to recoil or re expand
- compress at a rate of 100 per minute
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SYNCOPE
• Most commonly observed emergency in dental office-50% by Malamed and Fast et al
• Transient loss of conciousness• Decreased cerebral perfusion• Critical level of blood flow- 30mL of blood
per 100g of brain tissue per minute
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SYNCOPE
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Syncope-clinical features
Early• Nausea• Warmth• Perspiration• loss of color• Baseline Blood press• Tachycardia
Late• Hypotension• Bradycardia• Hyperpnea• Pupillary dilation• Peripheral coldness• Visual disturbance• Loss of
consciousness
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Syncope- Management
1. Assessment of unconciousness- shake and shout
2. ABC3. Definitive care
-administration of O2
-monitoring vitals -additional procedures
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POSTURAL HYPOTENSION
• 2ND leading cause• Drop in systolic BP of 30mmHg or
10mmHg drop in diastolic BP
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Predisposing factors
1. Administration and ingestion of drugs- vasodilators, α blocker, β blocker
2. Prolonged recumbency and convalescence3. Inadequate postural reflex4. Pregnancy- supine hypotensive syndrome of
pregnancy5. Venous defects in legs6. Chronic postural hypotension(shy-drager
syndrome)7. Physical exhaustion and starvation
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Management
• Same as syncope• ABC• Changes in posture should be done slowly
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RESPIRATORY DISTRESS
• OBSTRUCTED AIRWAY• HYPERVENTILATION• ASTHMA
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OBSTRUCTED AIRWAY
• Foreign body aspiration• Laryngeal edema
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PREVENTION
• Rubber dam• Oral packing- pharyngeal curtain• Chair position• Suction• Magill intubation forceps• Ligature- dental floss
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Management
• 1 Recognize un conciousness• 2 Call for help • 3 Position victim (supine) • 4 head tilt • 5 Assess airway and breathing • 6 Attempt to ventilate • 7 Reposition head (head tilt) and attempt to
ventilate • 8 Jaw thrust maneuver
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Management –contd.
• 9 Attempt to ventilate • 10 Activate EMS system • 11 Deliver 6 to 10 abdominal thrusts • 12 Check mouth for foreign body • 13 Attempt to ventilate • 14 Repeat steps 11 to 13 until successful • 15 Cricothyrotomy
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Cricothyrotomy
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HYPERVENTILATION
• Ventilation in excess of that required to maintain normal blood PaO2 and PCO2
• Increase in depth or frequency• Almost always a result of extreme anxiety
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Clinical features
• Palpitations • Tachycardia • Dizziness• Numbness or tingling of extremities• Dryness of mouth• Shortness of breath• Tremor
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Management
• Termination of dental procedure• ABC• Removal of materials from mouth• Calming the patient- reassurance• Drug management if necessary
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ASTHMA
• Chronic inflammatory disorder characterised by reversible obstruction of the airways
• 2 categories- extrinsic(allergic)- intrinsic(non allergic/idiopathic)
• Status asthmaticus- most severe clinical form-wheezing, dyspnoea,hypoxia
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Management
• Termination of dental therapy• ABC• Administration of O2 • Administration of bronchodilators like
albuterol• In sevete cases call for assisstance
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DRUG OVERDOSE REACTIONS
• Can be due to- local anaesthetics- antibiotics-analgesics
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Local anaesthetic overdose reaction
• SIGNS• Low to moderate
-confusion- talkativeness- excitedness- slurred speech- elevated BP, heart rate, resp. rate
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• Moderate to high- generalised tonic clonic seizure- CNS depression- depressed BP, heart rate, resp. rate
• SYMPTOMS-Headache-dizziness-blurred vision-drowsiness-disorientation
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Management
• Termination of procedure• ABC• Administration of O2 • Administration of anti convulsant if needed• Medical assisstance
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ALLERGY
• A hypersensitive state acquired through exposure to a particular allergen, re-exposure to which produces heightened capacity to react
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Gell & Coombs Classification
• Type 1 ( IgE – Mediated Hypersensitivity)-most life threatening-few minutes• Type 2 ( Cytotoxic / Cytolytic antibody
mediated) -IgM or IgG antibodies mediate• Type 3 ( Immnune complex mediated )-1- 4 weeks, IgM – IgG soluble metabolite• Type 4 (delayed Hypersensitivity )-sensitized T cell lymphocytes
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Anaphylaxis
• SIGNS AND SYMPTOMS• Paraesthesia, flushing, facial swelling• Generalised itching – hands and feet• Bronchospasm and laryngospasm
(wheezing and breathing difficulty)• Rapid weak pulse together with fall in
blood pressure
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Management
• ADRENALINE (Epinephrine)• Immediate administration of IM
epinephrine 1:1000 in a dose of 0.3mL(0.3 mg adult)
• Administered every 5 to 20 minutes• If IV route available administer 1 mL of
1:10000(0.1mg) by slow IV push over 3-5 minutes
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SEIZURES
• Manifestation of brain dysfunction• Excessive neuronal cortical discharge• Secondary to toxins, drugs, cerebral
hypoxia, or metabolic disturbances
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Types
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Causes
• Congenital abnormalities• Perinatal injuries• Metabolic and toxic disorders• Head trauma• Tumors • Vascular diseases• Infectious diseases
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Management
• Termination of procedure• ABC• Prevention of injury• Monitoring vitals• Reassurance • Medication should only be given if
convulsive seizures are prolonged or last 5 minutes or more or are repeated rapidly
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• Usually used drug is a benzodiasepine either diazepam-5-10mg via IV route at a rate of 5mg per minute and repeated every 10-15 minutes to a max. Dose of 30mg or midazolam 10 mg
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HYPOGLYCEMIA
• Inadequate food intake• Excessive insulin dose• Oral hypoglycemic therapy• Strenuous exercise• Alcohol intake• Kidney failure, liver failure
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Clinical features
• EARLY STAGE-diminished cerebral function- changes in mood - hunger- nausea
• MORE SEVERE STAGE-sweating-tachycardia
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-piloerection- increased anxiety- poor judgement- un cooperativeness
• LATER SEVERE STAGE-un conciousness- seizures- hypotension-hypothermia
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Management
• Termination of procedure• ABC• Summoning medical assisstance• Administration of carbohydrates
-IV injection of 50%Dextrose solution-glucagon IM- epinephrine IM
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ADRENAL INSUFFICIENCY
• Deficiency of adrenal hormones- ADDISONS disease-primary
exogenous corticosteroid therapy-secondary
• Signs and symptoms – Loss of consciousness– Rapid, weak or impalpable pulse– Blood pressure falls rapidly
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Management
• Termination of procedure• ABC• Recognition of unconciousness• Administration of glucocorticosteroids
- 100mg hydrocortisone IM or IV
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Chest pain
• Angina pectoris- most common• Hyperventilation• Myocardial infarction
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ANGINA PECTORIS
• Dr. William Heberden in 1768• A characteristic thoracic pain, usually
substernal; precipitated chiefly by exercise, emotion or heavy metal; relieved by vasodilator drugs and few minutes rest
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Management
• Terminate procedure• ABC• oxygen• Position patient comfort• Vitals • Emergency Medical Service • Vasodilators-Nitroglycerin : spray or tab 0.4mg
repeat three times every 5 min not more than 3 doses
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MYOCARDIAL INFARCTION
• Caused by deficient coronary arterial blood supply to a region of myocardium resulting in cellular death and necrosis
• Main cause is atherosclerosis
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Clinical features
• SYMPTOMS- pain- severe to intolerable, prolonged(30 min)- nausea and vomiting- weakness- dizziness- palpitations-cold perspirations- sense of impending doom
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• SIGNS- restlessness- acute distress- skin- cool, pale, moist- heart rate- bradycardia to tachycardia
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Management • Termination of procedure• Diagnosis • ABC• Administer oxygen• Summon medical assistance• Administer nitroglycerin• Antiplatelet therapy• Monitoring vitals• Shifting to hospital
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TRIGEMINO-CARDIAC REFLEX
• First described in 1999 by B J Schaller et al
• phenomenon consisting of bradycardia, arterial hypotension, apnea, and gastric hypermotility
• The sensory nerve endings of the trigeminal nerve send neuronal signals via the Gasserian ganglion to the sensory nucleus of the trigeminal nerve, forming the afferent pathway of the reflex arc.
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• This afferent pathway continues along the short internuncial nerve fibers in the reticular formatio to connect with the efferent pathway in the motor nucleus of the vagus nerve.
• Koerbel et al found that the manifestations became normal once the stimulus was removed
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CONCLUSIONS
• Emergencies will occur• The use of emergency drugs is safe –
when the diagnosis is correct• The drug kit should be checked regularly
to ensure that it is up to date
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BIBLIOGRAPHY
• Handbook of Medical Emergencies in the Dental Office, Stanley F. Malamed
• Medical Emergencies in Dentistry, Jeffrey D. Bennett , Morton B.Rosenberg
• Trigeminocardiac reflex during skull base surgery: mechanism and management
A.Koerbel,A.Samii• Trigemino-cardiac reflex in humans initiated by
peripheral stimulation during neurosurgical skull-base operations. Its first description J.Schaller
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THANK YOU