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Medical

Emergencies in the
Dental Office

Life Threatening
Situations
w Factors to help decrease
wPretreatment physical evaluation
wMedical history questionnaire
wDialogue histoy
wPhysical examination
wModifications in dental care

Top 7 Emergencies
w Syncope
w Mild allergic reaction
w Angina pectoris
w Postural hypotension
w Seizures
w Bronchospasm
w Hyperventilation

Emergencies
w Most medical emergencies are
entirely stress induced
w Pain, anxiety, fear
w Exacerbation of preexisting
conditions due to stressful situations

Stress Induced Situations


w Vasopressor syncope
w Hyperventilation
w Acute cardiovascular emergencies
w Broncospasm
w Seizures

Drug-related adverse
reactions
Local Anesthetics
-psychogenic (stress related)
-overdose
-allergy

Common Medical
Emergencies
w Unconsciousness
w Vasodepressor
syncope
w Orthostatic
hypotension

w Airway obstruction
w Angina
w Acute myocardial
infarction
w Cardiac arrest
w seizures

w Hyperventilation
w Asthma
w Altered
consciousness
w Diabetes mellitus
w Thyroid gland dysfxn
w Cerebral vascular
accident

w Drug related
emergencies
w Drug overdose
reactions
w allergy

Prevention
w 90% of all life threatening situations
can be prevented with appropriate
physical exam
w 10% are sudden unexpected deaths
in spite of all preventative measures

Emergency Drugs
w Drug administration is not
necessary for the immediate
management of medical
emergencies
w Primary management of all
emergency situations involves BLS
w When in doubt, never medicate

Critical Injectable Drugs


w Epinephrine*
w Histamine blockers*
w Atropine
w * used in the management of acute
allergic reaction

Primary Injectable Dug


for Acute Allergic
Reaction (Anaphylaxis)
Drug of Choice Epi
Drug Class
Catecholamine
Trade Name
Ana-Guard,
Epipen, Epipen Jr.
Dose
1mg
Side Effects
Tachydysrhythmias

Primary Injectable for


Allergic Reaction
Drug of Choice
Drug Class
Indications
Side Effects

Dose

Diphenhydramine
Antihistamine
delayed onset allergic
reactions
drowsiness, dizziness,
urinary retention,
hypotension,
tachycardia
15-50mg, (25mg tabs)

Critical Noninjectable
Drugs
w Oxygen
w Vasodilator
w Bronchodilator
w Antihypoglycemic
w Aspirin

Primary Noninjectable
Vasodilator
Drug of Choice
Drug Class
Alternative
Indications
Side Effects
Dose

Nitroglycerin
Vasodilator
Amyl nitrate
Chest pain
Pulsating headache,
facial flushing,
hypotension
sublingual tabs
trans lingual spray

Primary Noninjectable
Antihypoglycemic
Drug of Choice
Drug Class
Alternative
Indications

Orange Juice pulp free


Antihypoglycemic
Soft Drink (not diet)
Hypoglycemic
secondary to diabetes
mellitus or fasting
hypoglycemic

Primary Noninjectable
Antiplatelet
Drug of Choice
Drug Class
Alternative
Indications
angina
Side effects

Aspirin
Antiplatelet
None
Suspected MI or
Hemmorrhage

Unconsciousness
w Account for 50% of all emergency
situations in the dental office
w Initial steps in the management of
unconsciousness, regardless of the
cause, remain the same
w Steps are directed toward basic life
sustaining procedures

Common Causes of
Syncope in Dental Office
w Vasodepressor syncope
w Drug administration of ingestion
w Orthostatic hypotension
w Epilepsy
w Hypoglycemic reaction

Management of
Unconsciousness
w Recognition
w Terminate dental procedure
w Call for help
w Initiate BLS

Presyncopal Signs and


Symptoms
w Early
wFeeling of warmth
wLoss of color
wHeavy perspiration
wNausea
wBP at baseline or lower
wtachycardia

Presyncopal Signs and


Symptoms
w Late
w Pupillary dilatation
w Yawning
w Heavy breathing
w Cold hands or feet
w Hypotension
w Bradycardia
w Visual disturbances
w Dizziness

Management of Syncope
w Position patient
w Administer oxygen
w Ammonia capsule
w Treat vitals if needed
w Postpone further treatment
w Determining precipitating factors
w Get up gradually
w Delayed recovery?
w Activate emergency medical services

Management of
Respiratory Distress
w Recognize respiratory distresssounds, abnormal rate or depth of
respiration

Respiratory Difficulty:
w Asthmatic attack:
wA paroxysmal state of hyperactivity
of the tracheobronchial tree;
bronchospasm or
bronchoconstriction caused by
allergin or non-allergic factors.
wPhysical finding:
wWheezing, coughing, chest tightness,
tachycardia, fatigue, airway
obstruction.

Asthmatic Attack:
w Management:
wPlace in comfortable position.
wAdminister inhalant therapy with
bronchodilator.
wOxygen.
wEpinephrine.
wCall for medical assistance.

Asthmatic Attack:
w Prevention:
wMinimize anxiety.
wHave medication available for use.
wHistory taking.

Hyperventilation
w Defined as ventilation in excess of
that required to maintain normal
blood PaO2 and PaCO2
w One of the most common
emergency situations that occur in
the dental office

Hyperventilation:
w Etiology: characterized by an
increase depth of ventilation.
Usually anxiety-related but may
occur with other conditions.
w Physical finding:
wDyspnea, air hunger, chest
tightness, hyperventilation, loss of
consciousness.

Hyperventilation:
w Management:
w Place in comfortable position.
w Guide patient in slow breathing.
w Let patient rebreathe his or her own exhaled air
by using paper bag of full-face mask.

w Prevention:
w Appropriate pain control and sedation techniques
to reduce anxiety.

Altered Consciousness
w Altered consciousness may be the
first clinical sign of a serious
medical problem
w Most common cause in the dental
setting is drugs

Causes of Altered
Consciousness
w Drug overdose
w Hyperventilation
w Hypoglycemia
w CVA
w Hyper/hypothyroidism

Management of Altered
Consciousness
w Terminate dental procedure
w Position
w BLS
w Manage signs and symptoms
w Call 911?

Vasovagal Syncope:
w Etiology: transient cerebral ischemia
leading to loss of consciousness, often
related to peripheral pooling of blood.
w Physical findings:
w Sudden loss of consciousness, pallor, nausea.
w Irregular and decreased ventilation.
w Hypotension and bradycardia.

Vasovagal Syncope:
w Management:
wPlace in comfortable position.
wEstablish a airway, oxygen
supplement.
wAdminister reflex stimulants;
Ammonia and cold compression.

w Prevention:
wMinimize anxiety and stress.

Orthostatic hypotension:
w Etiology: pooling of blood in the periphery
that is not remobilized quickly enough to
prevent cerebral ischemia when a patient
rapidly assumes an upright posture.
w Physical findings: palpitations and
generalized weakness, feel lightheaded or
become syncopal.

Orthostatic hypotension:
w Management:
wPosition patient in supine posture
with legs raised above the level of
the head.
wMonitor vital signs.

w Prevention:
wHistory taking.
wSlowly return patient to sitting
posture.

Diabetes Mellitus
w Represents a syndrome of
disordered glucose metabolism and
inappropriate hyperglycemia that
results from:
wAn absolute deficiency in insulin
wA reduction in the biologic
effectiveness of insulin
wOr both

Diabetes
Mellitus(hypoglycemia):
w Etiology: rapid decrease in serum blood
sugar usually seen in diabetics.
w Physical findings:
w Sudden decreased cerebral function
characterized by mental confusion, lethargy,
slurred speech.
w Hypotension, shock, eventual death.

Diabetes
Mellitus(hypoglycemia):
w Management:
wAdminister oral carbohydrate.
wOr IV infusion.

w Prevention:
wHistory taking.
wEarly recognition of insulin dose
and dietary habits.

Seizure:
w Etiology: paroxysmal neuronal discharge in
the brain characterized by altered
consciousness, uncoordinated muscle
activity or abnormal sensory phenomena.
w Physical findings:
w Tonic-clonic movements of trunk and extremities,
loss of consciousness, vomiting, airway
obstruction.

Seizure:
w Management:
w
w
w
w

Place patient supine position.


Suction and vital sign monitor.
Diazepam 5 mg IV.
BLS and transport if necessary.

w Prevention:
w History taking.
w Avoid toxic doses of local anesthetics.

Causes of High Blood


Levels of Local
Anesthetics
w Biotransformation of drug is slow
w Drug slowly eliminated by kidneys
w Total dose too large
w Rapid absorption at site
w Intravascular injection

Signs of Overdose
w Headache
w Lightheadedness
w Dizziness
w Blurred vision
w Ringing in ears
w Numbness
w Drowsiness, disorientation
w Loss of consciousness

Chest Pain!
w Cardiac
w Acute MI
w ischemia

w Noncardiac
w Musculoskeletal
w Pericarditis
w Esophagitis
w Pulmonary embolus
w Dissecting aortic aneurysm

Clinical Signs and


Symptoms
w Location: Not reliable - substernal
w Description: squeezing, tightness,
heaviness, crushing
w Response to medication: Most
reliable diagnostic tool

Clinical Management of
Chest Pain
w Termination of dental procedure
w Positioning
w BLS
w Administer oxygen and vasodilator

Nitroglycerine
w The single most effective drug for the
management of acute anginal episodes
w Decreases coronary artery resistance and
increases coronary blood flow - this is of
little consequence in patients with
significant CAD
w Preferable to administer patients own
medicine

Clinical Manifestations of
Acute MI
w Crushing pain, rarely described as
sharp, not relieved with rest, or
nitroglycerin
w Cold sweat
w Patient feels weak and apprehensive
w Dyspnea
w Nausea and vomiting

Management in Dental
Office
w Terminate procedure
w Diagnosis
w BLS (911?)/ACLS
w Administer oxygen
w Nitroglycerine - acts within 2-4 min
w Record vitals before and after meds
w administer fibrinolytic- aspirin

Local Anesthetic
Toxicity:
w Management:
wMonitor vital sign.
wAdminister oxygen.
wObserve for 1 hour.
wDiazepam (if convulsions occur)
wBLS and transport.

w Prevention: dose of local


anesthetics.

Local Anesthetic
Toxicity:
w Etiology: level of a narcotic resulting
in blood level producing adverse
reaction.
w Physical findings:
w Talkativeness, anxiety, slurred speech,
confusion.
w Stuttering speech, nystagmus, tremors,
headache, dizziness, blurred vision,
drowsiness.
w Seizure, cardiac dysrhythmia or arrest.

Thank You!!!!