Transcript Lecture 2 LRC

Medical Emergencies
Lecture 2
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Syncope (cerebral ischemia)
 Sudden, transient loss of consciousness and postural tone with
spontaneous recovery
 Possible causes
 loss of cerebral oxygenation and perfusion
 Often sign of another underlying condition
 Often associated with a stressful condition
 Most common medical emergency in the dental office
 Most syncopal episodes occur during the administration of local
anesthetics
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Syncope
 Affects all age groups
 More susceptible in children, pregnant mothers, and the elderly.
Children (15% of children have had at least one episode of syncope
before adolescence.) Causes:
 Missed meal
 Heat
 Dehydration
 Crying
 Exertional activity
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Syncope
 Elderly:
 Postural changes
 Defecation
 Coughing
 Orthostatic hypotension
 Medications
 Diseases: coronary heart disease, heart failure, diabetes,
renal insufficiency, chronic obstructive pulmonary disease
 Mortality rate from syncope for patients age 60 and older is
5 times higher than patients under 60.
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Signs and Symptoms of
Pre-Syncope
Pallor
Pupil dilation
Diaphoresis: cold sweat
Excitation of piloerector muscles
Weakness, dizziness, vertigo
Nausea, tingling in toes and fingers**
Yawning or sighing
Usually occur several minutes before loss of consciousness.
Table 5.1 pg 51 in book.
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Signs and Symptoms of
Pre-Syncope
Vision changes – darkening, blurring, seeing spots
Increased BP
Shortness of breath
Heart palpitations
Chest pain
Slow onset
Dental professional may see the patient become pale.
Place patient in Trendelenburg position**
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Signs and Symptoms of Syncope
Syncopal symptoms
◦ Unconsciousness
◦ Weak, slow pulse
◦ Low heart rate
◦ Pallor
◦ Flaccid muscles**
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Treatment of Syncope
Remove objects from oral cavity
Position supine with feet elevated
Open airway
Assess circulation
Loosen tight clothing
Administer oxygen, 4-6L/minute
Monitor vital signs
Treatment of Syncope
If unconsciousness persists summon EMS
Bradycardia 0.6 mg atropine IM
Longer patient in syncope more likely seizure will occur
Once consciousness returns
◦ Keep in supine position until patient feels well enough to be returned to upright
position and pulse returns to normal
Treatment of Syncope
Once consciousness returns
◦
◦
◦
◦
Suspend treatment for the day
Emergency contact should escort patient home as syncope can reoccur
If neurocardiac syncope suspected contact EMS
Thoroughly document syncope episode in chart
Figure 5.2 Patient in appropriate position for treatment of syncope
Types of Syncope
Cardiac syncope
Noncardiac syncope
Neurocardiac syncope
Preventing syncope in the
dental office**
Review medical history for past episodes of
syncope.
Help patient to relax and reduce anxiety;
build a good client-provider rapport; lowstress environment.
Patient’s who feel faint: recline dental chair
to Trendelenburg position (head lower than
legs)
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Treatment of Syncope
Remove objects from oral cavity
Position supine with feet elevated: presyncopal symptoms indicate a
50-70% decrease in blood flow to the brain.
Open airway
Assess circulation
Loosen tight clothing
Administer oxygen, 4-6L/minute
Monitor vital signs
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Treatment of Syncope
If unconsciousness persists summon EMS (unconsciousness can last
between a few seconds to minutes).
Longer patient in syncope more likely seizure will occur due to lack of
oxygen to the brain.
Ammonia inhalants are no longer recommended for use due to severe
complications.
Once consciousness returns
 Keep in supine position until patient feels well enough
to be returned to upright position and pulse returns to
normal
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Treatment of Post-Syncope**
 Once consciousness returns
 Suspend treatment for the day
 Emergency contact should escort patient home as
syncope can reoccur within the first 24 hours of the
first episode.
 If neurocardiac syncope suspected contact EMS
 Thoroughly document syncope episode in chart
 At the next dental appointment, the patient may
need anti-anxiety medications.
 The patient should be evaluated by a medical
doctor.
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Chapter 6
SHOCK
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Shock
Condition produced when the cardiovascular pulmonary system fails to deliver
enough oxygenated blood to body tissues to
support metabolic needs
Tissues use anaerobic (without air)
metabolic processes
Produces acidosis (increased acidity in the
blood) and harmful toxins
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Stages of Shock
Initial
Compensatory
Progressive
Refractor
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Stages of Shock
Initial – first stage
◦Cells deprived of oxygen
◦Inhibits ability to produce energy
◦Cells not functioning properly
◦Impacts body systems
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Stages of Shock
Compensatory (2nd stage) – body performs physiological
adaptations in an attempt to overcome shock
◦ Increased respiration to increase oxygen to cells
◦ Increased blood pressure to compensate for hypotension
(low blood pressure)
◦ Reduced blood supply to peripheral organs to improve
blood supply to brain
◦ Reduced blood flow to kidneys with resulting oliguria
(reduced urine output)
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Stages of Shock
Progressive ( 3rd stage) – compensatory
mechanisms begin to fail
◦If the problem causing shock is not treated,
condition will worsen
◦Vital organs compromised and not functioning
appropriately
◦Systolic hypotension (low BP)
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Stages of Shock
Refractory (4th stage) – failure of vital organs
◦Irreversible
◦Cell death and brain damage have occurred
◦Death will occur in a few hours
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Types of Shock
Hypovolemic
Cardiogenic
Distributive
◦Anaphylactic
◦Septic
◦Neurogenic
Obstructive
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Hypovolemic Shock
Most common form. A state of decreased
blood volume.
Caused by inadequate venous return to the
heart
Etiologies:
◦ Hemorrhage or dehydration (vomiting or
diarrhea)
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Hypovolemic Shock
Initial symptoms:
◦Peripheral vasoconstriction causing an
elevated diastolic BP
◦Increased heart rate
◦Rapid, thready pulse
◦Cool skin
◦Reduced urine output
◦Confusion
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Hypovolemic Shock
 Treatment
 Stop the bleeding, diarrhea, or vomiting that is
causing the shock.
 Supine position
 Call EMS
 ABC’s of CPR
 Monitor vital signs
 Administer oxygen 4-6L/minute
 IV fluids to restore circulating blood volume
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Cardiogenic Shock
Reduction in perfusion due to decreased cardiac output. Heart fails to pump
enough blood to supply oxygen to the peripheral tissues and body organs.
Etiologies (Can be caused by) damage to the heart due to….
◦ MI (heart attacks)
◦ Cardiac arrhythmias
◦ Cardiac dysfunction
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Cardiogenic Shock
 Signs and symptoms

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

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

Reduction in BP with systolic below 90 mmHg
Fast, weak pulse
Cold, clammy skin
Cyanosis: blue or purple color of skin due to the
tissues receiving less oxygen
Non-specific chest pain
Shortness of breath
Reduced urine output and confusion
Mental confusion
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Cardiogenic Shock
Treatment
Supine position (Face up)
Contact EMS
Monitor vital signs
Administer oxygen using a non-rebreather mask
Needs IV fluids: treatment provided in
ER
Cardiac medications needed: beta
blockers or vasodilators
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Distributive Shock
Vasogenic shock (another name for
distributive shock)
◦3 types: result from vasodilation and
abnormal distribution of fluids in the
circulatory system.
◦Anaphylactic
◦Septic
◦Neurogenic
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Anaphylactic Shock
Sudden, massive vasodilation and circulatory
collapse following exposure to an allergen
Will be discussed in detail later in Allergy
chapter
Treatments: epinephrine, histamine blockers, or
corticosteroids.
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Septic Shock
Also called: Vasodilatory shock
Bacteria (particularly gram-negative bacilli)
invades bloodstream and causes an
inflammatory response to try to rid itself of
the invader
Result of a severe infection.
Can cause multiple organ failure and death.
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Septic Shock
 Signs and symptoms
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







Fever, vasodilation (widening of blood vessels)
Increased cardiac output
Tissue edema (swelling)
Pink, warm skin
Restlessness
Tachycardia (rapid heart rate)
Thirst
Eventual respiratory failure
Vasodilation causes the patient to appear pink &
warm, which differs from all other forms of shock
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Septic Shock
 Signs and symptoms
 Can cause microthrombi formation (small blood clots)
 Often fatal and cause multiple organ failure.
 Usually seen in elderly individuals, individuals with
poor nutritional status, neonates (babies), critically ill,
and immunocompromised patients
 hypotension, restlessness, anxiety, tachycardia, thirst,
respiratory failure.
 Treatment: fluids, antimicrobial therapy, possible
surgery to reduce or eliminate the infection.
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Neurogenic Shock
Loss of sympathetic nerve activity (activates the fight or flight
response) from brain’s vasomotor center, which regulates blood
pressure, due to an emotional trauma, disease, drug, or traumatic injury
to brain or spinal cord
Loss of sympathetic nerve activity causes peripheral dilation (expansion
of blood vessels) leading to reduction in venous return, thus causing
decreased cardiac output with hypotension (low blood pressure)
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Neurogenic Shock
Signs & symptoms
◦Hypotension (low blood pressure)
◦Bradycardia (low heart rate)
◦Brain and kidneys at risk of failure
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Neurogenic Shock
Treatment
◦Position supine
◦Contact EMS
◦Monitor vital signs
◦Needs drug therapy to restore cardiac
output: like dopamine to promote
vasoconstriction, and epinephrine to
restore blood pressure and cardiac output.
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Obstructive Shock
 Results from indirect heart pump failure
 Leads to decreased cardiac function and reduced circulation
 Etiologies
 arterial stenosis: narrowing of an artery
 pulmonary embolism: blockage of the main artery of
the lung or a branch of the lung by a substance that
has traveled through the blood stream.
 cardiac tamponade: when fluid fills up the sac around
the heart faster than the sac can stretch.
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Obstructive Shock
Symptoms
◦ Severe Hypotension: low blood pressure
◦Dyspnea: shortness of breath
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Obstructive Shock
Treatment
◦Position supine
◦Contact EMS
◦Monitor vital signs
◦Needs IV fluids
◦Relieving source of obstruction essential,
surgical intervention often required
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Hyperventilation
 A condition whereby rapid, deep breathing occurs, thus
eliminating more carbon dioxide than is produced
 Normal respiration rate for an adult: 12 – 20 RPM
 Rarely exceeds 22 RPM
 A person hyperventilating might have a RR: 22-40
 Affects 6–15% of population
 More common in females age 30 – 40
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Hyperventilation
Optimal pH 7.4 – slightly alkaline
Hyperventilation – pH 7.5 or higher
This minor change can have significant
physiological effects
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Hyperventilation
 Common when individuals are exposed to high altitudes, are pregnant,
take CNS stimulants, experience aspirin toxicity, or are extremely anxious
 CNS drugs- Central nervous system stimulatory drugs, such as:
antidepressants, hallucinogens, marijuana, lidocaine, benzocaine,
codeine, hydrocodone, morphine, diazepam.
 Lack of carbon dioxide in the arterial blood system (hypocapnia) leads
to respiratory alkalosis (increase in the pH of blood) and cerebral
vasoconstriction.
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Signs and Symptoms
Table 7.1 pg 67
Hypocalcemia – reduction in calcium levels in blood
Symptoms mimic pulmonary embolism – blockage of pulmonary artery –
can be fatal – patients often die within 2 hours of onset
Signs and Symptoms
 Most common symptoms: Abnormally prolonged
rapid and deep respirations
 Decrease in carbon dioxide causes vasoconstriction of
blood vessels leading to decreased cardiac output –
can cause palpitations and chest pain
 Impairment of problem solving abilities, motor
coordination, balance, and perceptual tasks due to lack
of oxygen to the brain.
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Figure 7.1 Lorazepam
Treatment
 Operator remain calm
 Place patient in position of their choice – usually upright
 Loosen tight clothing in neck region
 Work with patient to control rate of respirations
 Have patient count to 10 in one breath
 Breathe through pursed lips or nose
 NO MORE PAPER BAGS: can cause suffocation and
cardiac arrest.
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Treatment
Monitor vital signs
DO NOT administer oxygen-it can make the
condition worse.
If symptoms do not improve administer
benzodiazepine (Lorazepam 1-2 mg IM or
Diazepam 2-5 mg IM)
If symptoms do not improve contact EMS
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Seizure
Temporary episode of behavior alteration due to massive abnormal electrical
discharges in one or more areas of the brain.
Changes in consciousness-involuntary contractions of the muscles.**
Epilepsy or seizure disorder: condition where a person has recurrent seizures
and convulsions.**
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Seizure
Can be recorded on EEG
May be accompanied by convulsions or other neurological, sensory, or
emotional changes
Can be caused by systemic distress – isolated non-recurrent attacks
◦ Hypoxia
◦ Hypoglycemia
◦ Seizures
Preventing Seizure Activity
Medical History: identifying patients with a past history of seizures or
convulsions.**
Evaluate medications the patient is taking to control seizures and if
the patient has taken their seizure medications.**
Schedule shorter appointments early in the day.**
DO NOT use Nitrous Oxide on seizure patients**
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Epilepsy
•Common disorder
•2 million in the United States
•Seizures most common are neurological disorders
in pediatrics
Epilepsy
• Initial seizures in adults usually due to trauma,
disease, or stroke.
• A Seizure is not a disease, but a symptom of CNS
dysfunction
• Seizures not usually life-threatening
• Rare cases if seizure continues without stopping or
without a recovery period (status epilepticus) it
becomes a true medical emergency and appropriate
therapy is needed to prevent death.
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Etiology of Seizures
Cellular level – several theories
◦ Alterations in cell membrane permeability
◦ Decreased inhibition of cortical or thalamic neuronal activity
◦ Changes in cell structure that alter cellular excitability
◦ Imbalances in neurotransmitters
Classification of Seizures
 Two broad categories
 Primary/unprovoked or idiopathic
 Usually part of epileptic syndrome
 65% of seizures are of this kind
 Genetic tendency
 Usually require daily anti-seizure medication
 Secondary/provoked or acute symptomatic
 35% of seizures are of this kind
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Seizures in Dental Setting
 Several potential etiologies
 Hypoglycemia
 Hypoxia – secondary to syncope
 Local anesthetic toxicity
 Epilepsy
 Hypoglycemia, hypoxia and local anesthetic toxicity
can be prevented by appropriate patient management
and taking a thorough medical history.
 Reducing stress will help prevent seizures caused by
epilepsy.
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Types of Seizures
Partial seizures
◦ Simple partial with no loss of consciousness
◦ Jacksonian
◦ Sensory
◦ Complex partial
Partial (Focal/Local) Seizures
Most common type of seizure among newly diagnosed adults.
Come from a localized area in the brain, but can spread to the entire brain
causing a generalized seizure.
Signs and symptoms depend on the area affected in the brain.
Two major types of partial seizures: simple and complex.
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Simple Partial Seizures
Symptoms
◦ Foul smells
◦ Aura
◦ Visual – occipital lobe
◦ Auditory – temporal lobe
◦ Amnesia often follows
◦ Auras now considered to be a simple partial seizure with
impending complex or generalized seizure
Simple Partial Seizures
Consist of motor, sensory, or psychomotor changes with NO loss
of consciousness.
Symptoms: illusions, déjà vu, flashing lights, hallucinations,
tingling and creeping sensations, vertigo, sounds, and foul smells
or auras.
Symptoms may reflect the area of the brain activity: visualoccipital lobe; auditory-temporal lobe; olfactory.
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Simple Partial Seizures: Auras
Symptoms:
 Aura – sensory symptom occurring at onset of
seizure.
 Signals the beginning of abnormal changes in a focal
area of the brain.
 Typical auras include strong smells, nausea, mood
changes, unusual tastes, visual disturbances lasting
only a few seconds.
 Amnesia often follows
 Auras now considered to be a simple partial seizure
which serve as a warning sign of impending complex or
generalized seizure.
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Complex Partial Seizures
 Signs and symptoms
 Lose contact with surroundings – a few seconds to
20 minutes
 Automatisms – repetitive, non-purposeful activity
(lip smacking, grimacing, patting, wandering in
circle unintelligible speech)
 At the end of motor activity – mental confusion or fear
Generalized Seizures: Tonic-Clonic (GTCS) or
Grand Mal Seizures
Most common type of seizure disorder.
Occurs equally in males and females, and at any age.
Most GTCS occur by puberty.
Specific sequence of events from the warning phase to recovery, not all
patients experience all events.
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Phases of GTCS
Generalized Tonic-Clonic Seizures (GTCS)
◦ Specific sequence
◦ Aura
◦ Preictal Phase
◦ Ictal
◦ Tonic phase
◦ Hypertonic phase
◦ Clonic phase
◦ Postseizure or postictal phase
Four stages of GTCS: first stage is aura
Aura or prodromal phase. (also discussed under simple partial seizures)
 Considered to be a simple partial seizure, an aura is a
sensation that precedes seizure activity.
 Some people experience changes in emotional state, such
as extreme anxiety or depression.
 Most have the same aura experience prior to a seizure.
 The amnesic effect of seizures causes the person to not
remember experiencing an aura.
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Preictal Phase: second stage
Occurs soon after aura
Patient loses consciousness
May fall if standing – the most common cause of
seizure related injuries.
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Ictal Phase
Tonic phase
◦ Muscles have sustained contraction – patient appears rigid
◦ Produces loud cry – epileptic cry or crowing
◦ Dyspnea and cyanosis due to contraction of respiratory muscles
Hypertonic Phase
◦ Extreme muscle rigidity
Ictal Phase continue
Clonic phase
◦ Muscular contractions and relaxation
◦ Clenched jaw
◦ Saliva + air = froth at mouth
◦ Blood from biting tongue or soft tissues
◦ 2-5 minutes – gradually slow with final flexor jerk
Post-Ictal Phase
Movement stopped
Patient remains unconscious
CNS, CVS, and respiratory system depression
CNS and respiratory may lead to airway obstruction –
time when death is most likely
Post-Ictal Phase
 Muscle relaxation – urinary or fecal incontinence
 Patient awakens – confused, fatigued, wanting to sleep, amnesia
 Lasts for minutes to several hours
Fourth Ictal Phase
 Postseizure or postictal phase:
 Movement stopped, pt remains unconscious.
 When seizure stops, depression occurs in the central nervous system,
cardiovascular, and respiratory systems, related to how severe the
seizure was.
 Depression of the CNS and respiratory systems may lead to airway
obstruction the time when death is most likely to occur.
 Muscle relaxation after the first minutes after the seizure causing
urinary and/or fecal incontinence,
 Patient awakens – confused, fatigued, wanting to sleep, amnesia,
 Lasts for minutes to several hours, close observation essential to
protect the airway.
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Treatment of Seizures
 Primary task in the dental office is to try
and prevent injury to the patient having the
seizure.
 Specific steps should be followed depending
on the type of seizure.
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Treatment of GTCS Seizures
Primary task
Cease dental treatment
Remove instruments from mouth
Move equipment out of the way
Loosen tight clothing
Place in supine position
Treatment of GTCS Seizures
Leave patient in dental chair
Contact EMS
ABC’s of CPR
Monitor vital signs
Gently restrain to prevent injury
Treatment of GTCS in the dental office
If the patient is in the chair, do not move patient, but lower the chair and help
prevent patient from falling by positioning one person at the head and one person
at the foot of the chair.
Call EMS if the seizure last longer than 3 minutes or the patient becomes cyanotic.
Give oxygen 6-8 L/min through a non-rebreather mask.
CABs of life support provided if needed, vitals should be monitored.
Pt should be gently restrained to prevent injury.
Do NOT place anything into the patient’s mouth.
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Status Epilepticus
 Status epilepticus or continuous GTCS or repetitive recurrence of any type of
seizure without recovery between episodes.
 Life-threatening situation
 May persist for hours or days and is the major cause of mortality related to
seizure disorders.
 Temperature may rise to 106° F, tachycardia and dysrhythmias may occur, and
BP elevated to 200/150.
 Uninterrupted grand mal status may continue until death occurs as a result of
cardiac arrest, irreversible brain damage due to lack of oxygen, or a significant
decrease in blood glucose levels.
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Status Epilepticus
Incidence of grand mal status has decreased
due to effective antiseizure medications.
If a tonic-clonic seizure does not stop after 5
minutes, the use of anticonvulsant drugs may
be necessary-call EMS.
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Absence or Petit Mal Seizures (nonconvulsive)
Neither generally pose a problem during dental treatment.
If one of these seizures occurs, stop dental treatment, protect the
pts airway.
Remove all instruments from the pts mouth.
Monitor vital signs.
Treatment can continue at the end of the seizure if the pt has no ill
effects.
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Prevention for Known Seizure Patients
 Discuss with patients who respond
positively to seizures on their med
hx:
 Recent illnesses, stress, hormone
fluctuations, fatigue
 Recent hx of head trauma
 Recent hx of fever, headache, stiff neck
 Alcohol or substance abuse
 General physical




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condition, including
depression
Taking prescribed meds on
schedule
Info about seizure history
Alteration or loss of
consciousness
Postictal systems such as
confusion or amnesia
Prevention strategies in the dental office
 Clinician may wish to postpone
dental tx if there are risk factors
indicated in the patient’s medical
hx.
 Blood glucose levels, fatigue, and
anxiety are common triggers for
seizures in poorly controlled
cases.
 Patient’s doctor may need to be
consulted.
 Best time to tx seizure pts:
early morning appts, after pts
have eaten and within a few
hours of taking antiseizure
meds.**
 Irritability is often a symptom
that a seizure is coming.
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Cerebrovascular Accident (CVA)
AKA stroke
Abnormal condition of the brain
Leads to cell death
Second leading cause of death world wide
US
◦ third leading cause of death and disability
Risk Factors for CVA
Age
African Americans
Atrial fibrillation
◦ 2 million Americans
◦ Two atria quiver
◦ Heart pumps blood inefficiently resulting in pooling of blood –
leads to thrombi
◦ Increases risk of CVA five fold
Risk Factors for CVA
Oral contraceptives
Menopause due to estrogen changes
Diabetics
Familial history of CVA
Carotid Bruit – abnormal sound in carotid artery
Transient Ischemic Attacks
Brief episodes of neurological dysfunction
Last less than one hour
200,000 – 500,000 suffer from TIAs annually
10% of all strokes preceded by TIA
CVA often occur within first 4 days of TIA
Ischemic CVA
Blockage
Thrombus or embolus
85% CVAs – 60% thrombotic; 40% embolic
Core - central zone of ischemic tissue
Penumbra – surrounding tissue receiving diminished blood supply
◦ Potentially salvageable if blood supply restored quickly
Hemorrhagic CVA
Rupture
15%
Factors
Types of Hemorrhagic CVA
Intracerebral
Subarachnoid
Mortality
Pressure that is causing damage gradually diminishes and brain
regains some of its former function
Intracerebral CVA
Twice as common
Occurs when defective artery within the brain bursts
Surrounding tissue fills with blood
Blood places pressure on adjacent tissues
Due to ruptured artery other areas of brain ischemic leading to additional
damage
Subarachnoid CVA
Occurs when blood vessel on surface of brain ruptures and bleeds into
subarachnoid space
Blood places pressure on cerebellum causing pressure and damage to
brain cells
Signs and Symptoms of
Ischemic CVA
May stop and start again as stroke progresses
Severity and location
Altered level of consciousness
Pupils unequal and dilated
Confusion
Dizziness
Change in balance or coordination (ataxia)
Vision changes – loss of half the visual field
Signs and Symptoms of
Ischemic CVA
Deviation of tongue
Difficulty swallowing (dysphagia)
Speech changes
◦Poorly articulated speech (dysarthria)
◦Impairment of speech (dysphasia)
◦Inability to understand spoken word
◦Inability to speak at all (aphasia)
Signs and Symptoms of
Ischemic CVA
Drooling
Weakness, numbness, or tingling in one side of face
Facial droop
Numbness or tingling in arm or leg or both on one side of
body (hemiparesis)
Nausea or vomiting
Signs and Symptoms of
Hemorrhagic CVA
Onset abrupt and rapid
Severe headache
Increased BP
Subarachnoid CVA – neck pain or stiffness
Inability to stand or walk
Papillary malalignment
Nausea or vomiting
Altered level of consciousness
Stroke Scales
Cincinnati Pre-Hospital Stroke Scale (CPSS)
Looking for facial palsy, arm motor weakness, dysarthria
◦ Ask patient to smile – observe for weakness on one side of face
◦ Ask patient to hold out both arms palm up and eyes closed for
10 seconds – observe for weakness in one arm
Stroke Scales
◦ Ask patient to repeat simple sentence – “The sky is blue in Cincinnati.”
– observe for difficulty in speech
◦ If any of the 3 components found to be abnormal then assume CVA
Treatment
Contact EMS immediately
Position semi-supine
BLS – check airway, breathing, and circulation
Administer O2 4-6L/min
Test glucose levels to rule out hypoglycemia
Treatment
Monitor vital signs
Transport to ED as soon as possible
Aspirin for ischemic CVA reduces death and recurrence rates
Aspirin for intracranial hemorrhage CVA patients also improved
outcomes – however not recommended
Treatment
In hospital
◦ CT scan to determine etiology
◦ Hemorrhagic – probably surgery
◦ Ischemic – < 3 hours onset of symptoms then IV thrombolytic therapy with
altaplase (r-tPa) – removes thrombus or embolus to restore blood flow
◦ Ineffective after 3 hours
◦ Contraindicated for hemorrhagic CVA
Click to add title
An epileptic cry caused by air rushing from the lungs may
occur during which stage of a grand mal seizure?
a. Preictal
b. Convulsive
c. Postictal
d. Characteristic of hysterical seizure
B
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