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Management

of
Medical Emergencies
in
Dental Practice

DR. SAAD BIN QASIM, B.D.S, MSC ( LONDON)


RESEARCH SCHOLAR
KING SAUD UNIVERSITY
COLLEGE OF APPLIED MEDICAL SCIENCES
DEPARTMENT OF DENTAL HEALTH.
CONTENTS

 What is an Emergency situation.


 Clinical presentation of emergency
 Basic Emergency Procedure
 Approach
 Collapse, Acute chest pain, Convulsion, Fainting
 Pain, Mechanism, Management, Prevention
 Anaphylactic Reaction.
 Diabetes,
 Thyroid crisis
 Asthma
 Angina
 MI,
 Stroke
What is an Emergency Situation ??

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)
Clinical Presentation of Emergencies

 Sudden loss of consciousness


 Chest pain & dyspnea
 Convulsions (fits)
Basic Emergency Procedures
APPROACH
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)
COLLAPSE

 Vaso-vagal syncope
 Acute Hypoglycaemia
 Anaphylactic shock
 Steroid crisis
 Myocardial Infarction
 Cardiac Arrest
 CVA
ACUTE CHEST PAIN OR DIFFICULTY OF
BREATHING

 Angina
 Myocardial Infarction
 Asthma
 Anaphylactic Shock
CONVULSIONS

 Epilepsy
 Any other cause of loss of consciousness
including fainting
FAINTING
Predisposing factors:
Stress Conditions

 Anxiety
 Pain
 Injections
 Fatigue
 Hunger
Mechanism

 Premonitory dizziness, weakness & nausea


 Pale, cold moist skin
 Pulse initially slow & weak, becoming full &
bounding
Management
 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)
Prevention

 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
Anaphylactic Reaction

 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
Type I Hypersensitivity

 Immediate
 IgE mediated
 Anaphylaxis
 Urticaria
 Angio-oedema
 Allergic Asthma
 Rhinitis
Adverse Reactions
•Hypersensitivity
Angio--oedema
Angio
Anaphylaxis
 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
Management of Anaphylaxis

 Lay flat with raised legs


 Give Adrenaline (1:1000) 0.3
0.3--0.5 ml SC or IM
 Hydrocortisone 200 mg i.v
i.v..
 Chlorpheniramine 10
10--20 mg slow i.v
i.v..
 Give oxygen 6L/min & assisted ventilation
 Consider Cricothyrotomy if NO quick
improvement
 Call an ambulance
Acute Hypoglycaemia

CAUSES: MANAGEMENT:
 Overdose of insulin  Glucose
tablets/powder
 Prevented from eating
at expected time  If unconscious give
50ml 50% glucose IV
 SC glucagon 1mg
The Diabetic Patient

Hypoglycaemia Hyperglycaemia

Rapid onset Slow onset


Irritability Drowsiness/disorientati
Moist skin on
Pulse full & rapid Dry skin & mouth
More common Pulse slow & weak
Less Severe Rare
Easy to be managed More Severe
Difficult to be managed
THYROID CRISIS (STORM)
Sudden, Severe Exacerbation of Hyperthyroidism

Precipitating Factors:

 Infection
 Surgery
 Trauma
 Pregnancy
 Other Physiologic or Emotional Stress
Management
Manifestations: Management:
 Hyperpyrexia  Terminate all dental
(Fever) ttt
 Tachycardia  Summon medical
 Agitation assist
 Palpitation  Administer O2
 Monitor VS
 Nausia
Nausia,, Vomiting
 Initiate BLS, if
 Abdominal pain
necessary
 Loss of
 Start IV line & Fluids
Consciousness
 Transport to ER Care
(Partial or
Complete)
STEROID CRISIS
Circulatory Collapse
The Pt Problem
Adrenocortical Insufficiency: Primary (Addison`s
(Addison`s Disease); Rare
Secondary (Exogenous ttt
ttt);
); more common (20 mg cortisol
daily/2weeks/year)

CAUSES: Stress SIGNS & SYMPTOMS


Conditions  Pallor
 GA  Weakness
 Surgical/Other  Nausia
trauma
 Rapid, weak or
 Infection impalpable pulse
 Other stress  Loss of consciousness
 Rapidly falling BP
Steroid Crisis Management

 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
ASTHMA
Causes
 Anxiety
 Infection or exposure to
specific allergen
 Loss or forgetting to bring
Salbutamol inhaler
Asthma
Signs & Symptoms
 Breathlessness
 Expiratory wheezing may be
disguised as shallow breathing
 Rapid pulse over 110
 Accessory muscles of
respiration brought into use
 Cyanosis of mucous
membrane & nail beds
 Mental confusion
Asthma
Management
 Reassure the patient
 DO NOT lay the patient
flat
 Give the anti asthmatic
drug 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
Angina

 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
Myocardial Infarction

 Severe, crushing retro-


sternal pain
 Feeling of impending
death
 Weak or irregular pulse
 Pain may radiate to left
shoulder, arm or jaw
 Shock, loss of
consciousness
 Vomiting
Myocardial Infarction

 Place patient in a comfortable position


allowing easy breathing
 Send for an ambulance
 Give 50/50 Nitrous Oxide/Oxygen or
Oxygen only
 Aspirin 300mg
 Good pain control
 Constant reassurance
Cardiac Arrest
Causes
 Myocardial Infarction
 Hypoxia
 Anaesthetic overdose
 Anaphylaxis
 Severe hypotension
CARDIAC ARREST
Signs, Symptoms & Management

 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
STROKE (CVA)
(CVA)

 Severe Headache
 Weakness or Paralysis of arms
or legs 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
CONVULSIONS (Epilepsy)
Grand mal, Petit mal (blank stare)

Predisposing factors:
 Anxiety
 Hunger
 Menstruation
 Alcohol
 External stimuli, flashing lights
etc
 Non compliance with
medications
Convulsions
Signs & Symptoms (Grand mal)

 Warning cry
 Immediate loss of consciousness
 Rigid (tonic phase)
 Widespread jerking (clonic
(clonic phase)
 Vomiting
 Flaccid after a few minutes
 Consciousness is regained after a variable
period
 Patient may remain confused
Convulsions
Management
 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
Status Epilepticus

 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
EMERGENCY KIT

 Telephone  Disposable needles


 Oxygen cylinder (23g)
 Laerdal pocket  Tourniquet
mask/Ambubag for
mask/Ambubag  Cannulae (20g)
hand ventilation  Portable suction
 Disposable airway equipment
(Sizes1--4) Guedel
(Sizes1  Sphygnomanometer/A
 Disposable syringes utomatic BP machine
(2,5,50 ml)  Pulse oximeter
DRUGS
 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%
Be Prepared

 Adequate training
 Protocols
 Medical history
 Prevention
 Checks& Updating