Transcript Management of Medical Emergencies in Dental Practice

Mohammad A. Elshall, BDS, MSc, PhD
Assist Prof and Consult Oral& Maxillofacial Surgery
College of Dentistry
King Saud University
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)
 Sudden loss of consciousness
 Chest pain & dyspnea
 Convulsions (fits)
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)
 Vaso-vagal syncope
 Acute Hypoglycaemia
 Anaphylactic shock
 Steroid crisis
 Myocardial Infarction
 Cardiac Arrest
 CVA
 Angina
 Myocardial Infarction
 Asthma
 Anaphylactic Shock
 Epilepsy
 Any other cause of loss of consciousness
including fainting
 Anxiety
 Pain
 Injections
 Fatigue
 Hunger
 Premonitory dizziness, weakness & nausea
 Pale, cold moist skin
 Pulse initially slow & weak, becoming full &
bounding
 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)
 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
 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
 Immediate
 IgE mediated
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Anaphylaxis
Urticaria
Angio-oedema
Allergic Asthma
Rhinitis
•Hypersensitivity
 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
 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
CAUSES:
 Overdose of insulin
 Prevented from eating
at expected time
MANAGEMENT:
 Glucose
tablets/powder
 If unconscious give
50ml 50% glucose IV
 SC glucagon 1mg
Hypoglycaemia
Hyperglycaemia
Rapid onset
Irritability
Moist skin
Pulse full & rapid
More common
Less Severe
Easy to be managed
Slow onset
Drowsiness/disorientation
Dry skin & mouth
Pulse slow & weak
Rare
More Severe
Difficult to be managed
Precipitating Factors:
 Infection
 Surgery
 Trauma
 Pregnancy
 Other Physiologic or Emotional Stress
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
CAUSES: Stress Conditions
 GA
 Surgical/Other
trauma
 Infection
 Other stress
SIGNS & SYMPTOMS
Pallor
Weakness
Nausia
Rapid, weak or
impalpable pulse
 Loss of consciousness
 Rapidly falling BP
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 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
 Anxiety
 Infection or exposure to
specific allergen
 Loss or forgetting to bring
Salbutamol inhaler
 Breathlessness
 Expiratory wheezing may be
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disguised as shallow breathing
Rapid pulse over 110
Accessory muscles of respiration
brought into use
Cyanosis of mucous membrane &
nail beds
Mental confusion
 Reassure the patient
 DO NOT lay the patient flat
 Give the anti asthmatic drug
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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
 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
 Severe, crushing retro
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sternal pain
Feeling of impending death
Weak or irregular pulse
Pain may radiate to left
shoulder, arm or jaw
Shock, loss of consciousness
Vomiting
 Place patient in a comfortable position allowing
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easy breathing
Send for an ambulance
Give 50/50 Nitrous Oxide/Oxygen or Oxygen only
Aspirin 300mg
Good pain control
Constant reassurance
 Myocardial Infarction
 Hypoxia
 Anaesthetic overdose
 Anaphylaxis
 Severe hypotension
 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
 Severe Headache
 Weakness or Paralysis of arms or legs
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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
Predisposing factors:
 Anxiety
 Hunger
 Menstruation
 Alcohol
 External stimuli, flashing lights etc
 Non compliance with medications
 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
 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
 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
The Recovery
Position
 Telephone
 Disposable needles (23g)
 Oxygen cylinder
 Tourniquet
 Laerdal pocket
 Cannulae (20g)
mask/Ambubag for hand
ventilation
 Disposable airway
(Sizes1-4) Guedel
 Disposable syringes
(2,5,50 ml)
 Portable suction
equipment
 Sphygnomanometer/Aut
omatic BP machine
 Pulse oximeter
 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%
 Adequate training
 Protocols
 Medical history
 Prevention
 Checks& Updating
http://faculty.ksu.edu.sa/elshall