Emergencies in Dental Practice
Content
EMERGENCIES IN DENTAL PRACTICE
Emergency in dental office are usually rare encounters since the practioners potential problems and manage them before because of an emergency. According to a study by Melamed revealed that hyperventilation ,seizures and hypo glycemia were the three most common emergencies before ,during or soon after being on the dental chair. Incidence of a medical emergency is seen mostly during or before a surgical care because of three factors namely ; 1. Surgeries stress provoking. 2. Greater number of medication is administered. 3. Longer appointment. Prevention of medical emergency is the corner stone of their management. Step One: Risk management Medical evaluation(history) Vital signs recorded Physical examination Step Two: Prevention is the best thing after prevention, deal with the management of medical emergency. Understand emergency problem Early recognition of the condition Start management as soon as the condition is recognized Call to the physician immediately. Make patient lie down supine position with head low and tilted to one side Maintenance of patent airway, breathing, circulation Oxygen may be administered in life threatening emergencies Vital signs to be monitored
Syncope
It is a transient loss of consciousness due to cerebral anoxia . It is also called fainting, common fainting attack or vasovagal attack. Generally occur because of series of cardio vascular event triggered by emotion stress brought by the anticipation of being delivered dental procedures. Other factors be anxiety ,fear, sight of blood , pain, extortion, fasting and hot environment These emotional stress release increase amount of catecholamines.
Pt complaints of being dizzy /weak, compensatory mechanism attempt to maintain adequate blood pressure but soon fatigue and lead to vagally mediated bradycardia. If severe, may lead to seizures.
Signs and Symptoms
Patient feels weakness warmth,nausea and pain in epigastrium and hunger before fainting. After this sweating dizzness pallor, light headedness and low pulse pressure develops. If treatment is not instituted patient develops unconsciousness, ashen grey color of skin, shallow respiration, decreased blood pressure weak pulse ,standing patient falls; may develop clonic jerks and twitching of facial muscles.
Management 1. 2. 3. Terminate the dental treatment. Position patient in supine posture with legs raised above level of head. Attempt to calm the patient.
4. 5. 6. 7.
Keep a cool towel on the forehead. Monitor vital signs. Tight clothing should be loosen. Check for breathing.
If absent a. Start basic life support. b. Medial assistance. c. Consider causes of syncope , hypoglycemia , cerebralvascular accident, cardiac dysrhythma If present a. b. c. d. Crush ammonia ampule under the patient nose. Admister oxygen. Vital signs to be recorded. Escort patient to his room.
Later,if the above doesn’t show results- 100% oxygen Bradycardia - __ atroprine 0.6mg dilute in 5ml of diluted water If hypotension is presents – vasopressor drugs Phenylephrine/methoxamine Prevention is the best way to treat syncope. 1. 2. 3. 2. SHOCK Clinical phenomenon marketed by circulatory deficiency which is either cardiac or vasomotor in origin exhibiting marked hypotension. Prime Shock is also called syncope which is not tackled and if persists then secondary appears. Seen on account of : Carry out dental proceed in semi-reclining position. Dentist should develop good rapport with patient to allay fears. Patient should be neither fasting nor full stomach.
1. 2.
Haemorrhagic shock – due to massive loss of internal bleeding. Hypovolumic Shock – due to fluid loss Eg. Seen in diarrhoea, dehydration
3. 4. 5. 6. 7.
Cardiogenic Shock – because of cardiac ailment. Septic Shock – due to toxemia. Anaphylactic Shock – during reaction Neurogenic Shock – following syncope Misc Shocks – hypo/hyper glycemia or adrenal insufficiency
Disparity between the circulating blood volume of the body and the volume capacity of the vascular tree This disparity is called cerebral ischemia. Signs and Symptoms
• • • • • • • • • •
Unconsciousness Ashen grey face Cold Clamming skin Lips, nails, lobule of ear – grayish blue Face expression – sunken eyes Pupils decaled Weak pulse Respiration shallow ,irregular ,rapid Temperature – subnormal Shock can be more easily prevented then treated.
Allergic Reaction
Allergy/hypersensitivity is an unwanted response of the body to a complete dose of the drug. It is as a result if an immunological response by the individual who has become sensitized to the drug through a prior exposure. It is an antigen-antibody reaction where the drugs behave as antigens by joining with tissue proteins/ polypeptides. Signs and Symptoms The least severe manifestation is dermatologic lesions ;which include uticaria,erythema,maculopapular or nodlar rash,petechial haemorrhages Allergic reaction affecting the resp track are more serious.They manifest as angioedema of tongue,eyelids,larynx and bronchi. In case of more severe reaction,patient may
complain of dyspnoea,wheezing,bronchospasm and many become cyanotic. Patients unable to speak produces stridors. Treatment
• • • • • • • • • • •
Patient is ( is trendlenberg position) with head lover than feet Maintain body heat by covering patient with blanket or hot water bottle Patient _____ Control of loss of blood - pressure packs etc Restore body fluids 100% oxygen – ad___eslened Vital aigns should be _____orced – BP,resperate,pulse Using hydro____ - 100mg dis in ____ H2O Using mephentismine – hypoti____ Atropine – pulse/ weak Broad space antibiotics – 1/V
Respiratory Emergencies 1. Hyperventilation
Denotes increase in alveolar ventilations disturbing the optimum levels of O2 and CO2. It is caused by abnormally rapid and deep breathing leading to respiratory alkalosis. It is often precipitated by anxiety, fear, nervousness and emotional stress etc. Commonly seen in females . Results in lowered level of CO2 in the blood or hypocapnoea and causes reduction in cerebral blood flow, decrease in peripheral resistance leading to hypotension which further leads to decrease in ionized Ca level in the blood followed by tetanic spasms Signs and Symptoms Dizziness, difficulty in breathing, palpitation, tingling sensation of fingers tips and toes,pain in chest, carpopedal spasm of tetany ,mental confusion , fatigue , loss of consciousness. Reactions 1. 2. 3. 4. Terminate dental procedures and remove foreign body from mouth. Position patient in upright position Verbally calm the patient Make patient breathe Co2 enriched air
5.
If symptoms worsen : Diasepam – 10mg 1/m or 1/v Midosolam – 4-5mg 1/m
6. 7.
Monitor vital signs Perform further dental surgery using anxiety – reducing measures
Manifestation 1. Delayed onset s___ signs ,erythema,_____ oerritis,anzioedema
Management
o o o o
Stop administration of all drugs. Administration im/iv benadryle 500mg or chlor-trimeton 10mg Refer physician Oral antihistaminic
Manifestation 2. Immediate onset s___ s___ ,erythema,urticaria, p____,anz___dima
Management
o o o o o o o o o
Stop adimn of all drugs Admis ep___phrine 0.3ml of 1:10000 1m/1v Repeat after 5mm Ademin 1m/1v Antihist Monitor vital signs frequency Consult physician Observe for 1hr Prescribe oral anti- histaminic
Manifestation 3. Respiratory signs with .without sking signs ____ing mild ___pnea
Management
• • • • • • • • • •
Stop adimin of all drugs Place in the sitting position Admen of epinephrinc Give oxygen 6/min by face mask/nasally Monitor vital signs Admen antihistaminic Provide 1v access Consult physician Observe for 1hr Prescribe antihistaminic
Manifestation 4. Stridorons brailing(crowning sound) moderate to severe dygshea
Management
• • • • • • • •
Top admen of drugs Sit in upright position Call for medical assist Ademin epi____phrine Give oxygen Vital signs Aol___ anti histaminic Provide 1v assess – if signs worry
Manifestation 5.Anaphylane is with or without skin signs – malaise wheezing ,mod- se-dysnea slendor ,cyanosis ,total airway obs, nausea and vomiting ,abd cramps,_____
inconlenence, tachycardia, hypotension, cardiac dysrlytheias, cardiac arrest Management Stop admin od all drugs Position patient’s supine on back board/on floor and summon assistance o Admin epine phrine initiate BLS o Vetal signs o Consider criothyrodonty o Give oxygen o Anolm of sntihist 1/v or 1/m o Prepare for transport
o o
Siezures
Management – Terminate Dent. Procedure Patient Position – supine with legs elevated medical assistance protect patient from injury basic life support oxygen monitor vital signs Drugs of voice Diazepam 10mg rate – 5mg/min Repeat every 10mins Children – 0-3mg/kg Unconscious Patient Patient Position – horizontal supine rain-heart same level feet elevated 10-15 degrees head down Pregnant – on right on left pillows etc patient venous return Adrenal Insufficiency
Patient who are on long term contrcosleroids for reaction of a variely of syscenue cored develop adrenal suppression If any patient is under stress the adrenal suppression prevents the normal release of glucocorticoids from the adrenal cortex. This is because of fall in production of ACTM secreted by anterior in response to the steroids ademin to the patient to the point . ACTM in turn controls the production of corticoids in the adrenal cortex. Management
• •
Terminate all dental Rx Position patient in supine position with legs raised above normal level of Medical assistance Admn of corticosleroid (___ing of hydrocorlesose) Adimin oxygen Vital signs 1/v drip crystalloid solution BLS Emergency
head
• • • • • • •
Pregnancy A resp to em and pl___ stress of Px large quantity of steroids are liberated into the blood stream .It secretes oxcylocim and lead to premature labour A patient is ____/_____ position can h___ pressure on __ venacave by the fractures leading to poor ___ return and hypolensurs . Turning patient onto the side will relieve the patient pressure and put the back to the normal. A patient supine hypolensron syndrome should be turned to left side in the reclining position and constantly reassured for a quick recovery. Asllrune Patient with H/O assllrune can be particularly challenge to manage safely.It may trigger due to em. Stress or any pharma agents.The signal of onset is Bronchospasm Patient complains of :
o o o
Shortness of breadth Sit erect(patients wants to) Wheezing in audible
o
tachypnea
may become : cyanolic hypoxic and loss of consciousness Management
o o o o o
terminate treatment repos- patients in sitting posture admin broncho_____ (___) admin oxygen monitor vital stats if reduced : refer physician if symptoms continue : ep____ - 0.3ml 1:10000
1m SC 1v 1/vdring crystalloid solution If vital signs reduce then refer physician If symptoms correct medical assistment theoplylin 1/v 250mg & corlisone 100mg 1/v emergency
Chest Discomfort
The app of chest discomfort is a patient who ___ __ is chaemic heart disease in the peri uperentive period caleis Clinical Features Discomfort pain, sneezing ,brushing ,pressing, burning, choking Subslirnarly located, may be radiated to left shoulder or left side neck or mandible . • Ass with exertion,heave metal ,anxiety etc • __ by vasodilators - ____ cernine etc • A_____ by dyspnea ,nausea, weakness, palpitations
• •
Treatment Position patient in semi reclurring posture Give nitrogycerine (TNG) 0.4mg tab or spray Admin oxygen Check pulse and blood pressure If: Continuous(3mins) 2nd dose TNG,moniter vital stats if not relieved, 3rd dose ,moniter vital stats if not relieved discomfort continuous then : 1. assume MI in progress 2. S_____ medical assistance 3. 1/v drip crystalloid sol. 30min/hr 4. Morphine Sulfate 5. Transport for Emmergency
Diabetes
Two types of problems are with diabetes
• •
Hypoglycemia/insulin shock Diabetic coma/keroacedosis/hyper glycerin
Hypoglycemia is seen frequently Manifestation Mild Moderate Severe
• • • •
Hunger tachycardia hypotension Nausea perspiration unconsciousness Mood change pallor siesures Weakness behavior change
Management Terminate Dental Procedures Mild
o
Moderate Admen glucose G
Severe admen 50ml of 50% G 1/v or 1mg glucagons Admen 50ml of 50% Medical
source fruit juice Monitor vital stats assistance
o
G or 1mg Consult physician oxygen
o
glucagons 1v or 1m
Admen
Emergency in dental office are usually rare encounters since the practioners potential problems and manage them before because of an emergency. According to a study by Melamed revealed that hyperventilation ,seizures and hypo glycemia were the three most common emergencies before ,during or soon after being on the dental chair. Incidence of a medical emergency is seen mostly during or before a surgical care because of three factors namely ; 1. Surgeries stress provoking. 2. Greater number of medication is administered. 3. Longer appointment. Prevention of medical emergency is the corner stone of their management. Step One: Risk management Medical evaluation(history) Vital signs recorded Physical examination Step Two: Prevention is the best thing after prevention, deal with the management of medical emergency. Understand emergency problem Early recognition of the condition Start management as soon as the condition is recognized Call to the physician immediately. Make patient lie down supine position with head low and tilted to one side Maintenance of patent airway, breathing, circulation Oxygen may be administered in life threatening emergencies Vital signs to be monitored
Syncope
It is a transient loss of consciousness due to cerebral anoxia . It is also called fainting, common fainting attack or vasovagal attack. Generally occur because of series of cardio vascular event triggered by emotion stress brought by the anticipation of being delivered dental procedures. Other factors be anxiety ,fear, sight of blood , pain, extortion, fasting and hot environment These emotional stress release increase amount of catecholamines.
Pt complaints of being dizzy /weak, compensatory mechanism attempt to maintain adequate blood pressure but soon fatigue and lead to vagally mediated bradycardia. If severe, may lead to seizures.
Signs and Symptoms
Patient feels weakness warmth,nausea and pain in epigastrium and hunger before fainting. After this sweating dizzness pallor, light headedness and low pulse pressure develops. If treatment is not instituted patient develops unconsciousness, ashen grey color of skin, shallow respiration, decreased blood pressure weak pulse ,standing patient falls; may develop clonic jerks and twitching of facial muscles.
Management 1. 2. 3. Terminate the dental treatment. Position patient in supine posture with legs raised above level of head. Attempt to calm the patient.
4. 5. 6. 7.
Keep a cool towel on the forehead. Monitor vital signs. Tight clothing should be loosen. Check for breathing.
If absent a. Start basic life support. b. Medial assistance. c. Consider causes of syncope , hypoglycemia , cerebralvascular accident, cardiac dysrhythma If present a. b. c. d. Crush ammonia ampule under the patient nose. Admister oxygen. Vital signs to be recorded. Escort patient to his room.
Later,if the above doesn’t show results- 100% oxygen Bradycardia - __ atroprine 0.6mg dilute in 5ml of diluted water If hypotension is presents – vasopressor drugs Phenylephrine/methoxamine Prevention is the best way to treat syncope. 1. 2. 3. 2. SHOCK Clinical phenomenon marketed by circulatory deficiency which is either cardiac or vasomotor in origin exhibiting marked hypotension. Prime Shock is also called syncope which is not tackled and if persists then secondary appears. Seen on account of : Carry out dental proceed in semi-reclining position. Dentist should develop good rapport with patient to allay fears. Patient should be neither fasting nor full stomach.
1. 2.
Haemorrhagic shock – due to massive loss of internal bleeding. Hypovolumic Shock – due to fluid loss Eg. Seen in diarrhoea, dehydration
3. 4. 5. 6. 7.
Cardiogenic Shock – because of cardiac ailment. Septic Shock – due to toxemia. Anaphylactic Shock – during reaction Neurogenic Shock – following syncope Misc Shocks – hypo/hyper glycemia or adrenal insufficiency
Disparity between the circulating blood volume of the body and the volume capacity of the vascular tree This disparity is called cerebral ischemia. Signs and Symptoms
• • • • • • • • • •
Unconsciousness Ashen grey face Cold Clamming skin Lips, nails, lobule of ear – grayish blue Face expression – sunken eyes Pupils decaled Weak pulse Respiration shallow ,irregular ,rapid Temperature – subnormal Shock can be more easily prevented then treated.
Allergic Reaction
Allergy/hypersensitivity is an unwanted response of the body to a complete dose of the drug. It is as a result if an immunological response by the individual who has become sensitized to the drug through a prior exposure. It is an antigen-antibody reaction where the drugs behave as antigens by joining with tissue proteins/ polypeptides. Signs and Symptoms The least severe manifestation is dermatologic lesions ;which include uticaria,erythema,maculopapular or nodlar rash,petechial haemorrhages Allergic reaction affecting the resp track are more serious.They manifest as angioedema of tongue,eyelids,larynx and bronchi. In case of more severe reaction,patient may
complain of dyspnoea,wheezing,bronchospasm and many become cyanotic. Patients unable to speak produces stridors. Treatment
• • • • • • • • • • •
Patient is ( is trendlenberg position) with head lover than feet Maintain body heat by covering patient with blanket or hot water bottle Patient _____ Control of loss of blood - pressure packs etc Restore body fluids 100% oxygen – ad___eslened Vital aigns should be _____orced – BP,resperate,pulse Using hydro____ - 100mg dis in ____ H2O Using mephentismine – hypoti____ Atropine – pulse/ weak Broad space antibiotics – 1/V
Respiratory Emergencies 1. Hyperventilation
Denotes increase in alveolar ventilations disturbing the optimum levels of O2 and CO2. It is caused by abnormally rapid and deep breathing leading to respiratory alkalosis. It is often precipitated by anxiety, fear, nervousness and emotional stress etc. Commonly seen in females . Results in lowered level of CO2 in the blood or hypocapnoea and causes reduction in cerebral blood flow, decrease in peripheral resistance leading to hypotension which further leads to decrease in ionized Ca level in the blood followed by tetanic spasms Signs and Symptoms Dizziness, difficulty in breathing, palpitation, tingling sensation of fingers tips and toes,pain in chest, carpopedal spasm of tetany ,mental confusion , fatigue , loss of consciousness. Reactions 1. 2. 3. 4. Terminate dental procedures and remove foreign body from mouth. Position patient in upright position Verbally calm the patient Make patient breathe Co2 enriched air
5.
If symptoms worsen : Diasepam – 10mg 1/m or 1/v Midosolam – 4-5mg 1/m
6. 7.
Monitor vital signs Perform further dental surgery using anxiety – reducing measures
Manifestation 1. Delayed onset s___ signs ,erythema,_____ oerritis,anzioedema
Management
o o o o
Stop administration of all drugs. Administration im/iv benadryle 500mg or chlor-trimeton 10mg Refer physician Oral antihistaminic
Manifestation 2. Immediate onset s___ s___ ,erythema,urticaria, p____,anz___dima
Management
o o o o o o o o o
Stop adimn of all drugs Admis ep___phrine 0.3ml of 1:10000 1m/1v Repeat after 5mm Ademin 1m/1v Antihist Monitor vital signs frequency Consult physician Observe for 1hr Prescribe oral anti- histaminic
Manifestation 3. Respiratory signs with .without sking signs ____ing mild ___pnea
Management
• • • • • • • • • •
Stop adimin of all drugs Place in the sitting position Admen of epinephrinc Give oxygen 6/min by face mask/nasally Monitor vital signs Admen antihistaminic Provide 1v access Consult physician Observe for 1hr Prescribe antihistaminic
Manifestation 4. Stridorons brailing(crowning sound) moderate to severe dygshea
Management
• • • • • • • •
Top admen of drugs Sit in upright position Call for medical assist Ademin epi____phrine Give oxygen Vital signs Aol___ anti histaminic Provide 1v assess – if signs worry
Manifestation 5.Anaphylane is with or without skin signs – malaise wheezing ,mod- se-dysnea slendor ,cyanosis ,total airway obs, nausea and vomiting ,abd cramps,_____
inconlenence, tachycardia, hypotension, cardiac dysrlytheias, cardiac arrest Management Stop admin od all drugs Position patient’s supine on back board/on floor and summon assistance o Admin epine phrine initiate BLS o Vetal signs o Consider criothyrodonty o Give oxygen o Anolm of sntihist 1/v or 1/m o Prepare for transport
o o
Siezures
Management – Terminate Dent. Procedure Patient Position – supine with legs elevated medical assistance protect patient from injury basic life support oxygen monitor vital signs Drugs of voice Diazepam 10mg rate – 5mg/min Repeat every 10mins Children – 0-3mg/kg Unconscious Patient Patient Position – horizontal supine rain-heart same level feet elevated 10-15 degrees head down Pregnant – on right on left pillows etc patient venous return Adrenal Insufficiency
Patient who are on long term contrcosleroids for reaction of a variely of syscenue cored develop adrenal suppression If any patient is under stress the adrenal suppression prevents the normal release of glucocorticoids from the adrenal cortex. This is because of fall in production of ACTM secreted by anterior in response to the steroids ademin to the patient to the point . ACTM in turn controls the production of corticoids in the adrenal cortex. Management
• •
Terminate all dental Rx Position patient in supine position with legs raised above normal level of Medical assistance Admn of corticosleroid (___ing of hydrocorlesose) Adimin oxygen Vital signs 1/v drip crystalloid solution BLS Emergency
head
• • • • • • •
Pregnancy A resp to em and pl___ stress of Px large quantity of steroids are liberated into the blood stream .It secretes oxcylocim and lead to premature labour A patient is ____/_____ position can h___ pressure on __ venacave by the fractures leading to poor ___ return and hypolensurs . Turning patient onto the side will relieve the patient pressure and put the back to the normal. A patient supine hypolensron syndrome should be turned to left side in the reclining position and constantly reassured for a quick recovery. Asllrune Patient with H/O assllrune can be particularly challenge to manage safely.It may trigger due to em. Stress or any pharma agents.The signal of onset is Bronchospasm Patient complains of :
o o o
Shortness of breadth Sit erect(patients wants to) Wheezing in audible
o
tachypnea
may become : cyanolic hypoxic and loss of consciousness Management
o o o o o
terminate treatment repos- patients in sitting posture admin broncho_____ (___) admin oxygen monitor vital stats if reduced : refer physician if symptoms continue : ep____ - 0.3ml 1:10000
1m SC 1v 1/vdring crystalloid solution If vital signs reduce then refer physician If symptoms correct medical assistment theoplylin 1/v 250mg & corlisone 100mg 1/v emergency
Chest Discomfort
The app of chest discomfort is a patient who ___ __ is chaemic heart disease in the peri uperentive period caleis Clinical Features Discomfort pain, sneezing ,brushing ,pressing, burning, choking Subslirnarly located, may be radiated to left shoulder or left side neck or mandible . • Ass with exertion,heave metal ,anxiety etc • __ by vasodilators - ____ cernine etc • A_____ by dyspnea ,nausea, weakness, palpitations
• •
Treatment Position patient in semi reclurring posture Give nitrogycerine (TNG) 0.4mg tab or spray Admin oxygen Check pulse and blood pressure If: Continuous(3mins) 2nd dose TNG,moniter vital stats if not relieved, 3rd dose ,moniter vital stats if not relieved discomfort continuous then : 1. assume MI in progress 2. S_____ medical assistance 3. 1/v drip crystalloid sol. 30min/hr 4. Morphine Sulfate 5. Transport for Emmergency
Diabetes
Two types of problems are with diabetes
• •
Hypoglycemia/insulin shock Diabetic coma/keroacedosis/hyper glycerin
Hypoglycemia is seen frequently Manifestation Mild Moderate Severe
• • • •
Hunger tachycardia hypotension Nausea perspiration unconsciousness Mood change pallor siesures Weakness behavior change
Management Terminate Dental Procedures Mild
o
Moderate Admen glucose G
Severe admen 50ml of 50% G 1/v or 1mg glucagons Admen 50ml of 50% Medical
source fruit juice Monitor vital stats assistance
o
G or 1mg Consult physician oxygen
o
glucagons 1v or 1m
Admen
