Medical Emergencies in Dentistry

Medical Emergencies in Dentistry

Definition
A serious unpredictable, unexpected potentially
dangerous situation that require immediate action
It can progress to mortality or neurological deficit
in a short space of time if not properly managed
 Physical Status Classification
American Society of Anaesthesiologists
●ASA I Normal healthy patient
●ASA II A patient with mild to moderate systemic
disease
●ASA III A patient with severe systemic disease
that limits the activity but not incapacitating
●ASA IV A patient with severe systemic disease
that limit the activity and is a threat to life
●ASA V A morbid patient not expected to live
long
How to Minimise Medical Emergencies

●Evaluation of the medical history

●Current and previous medications
●Physical examination
●Determination of medical risk and anxiety
●Dental care plan
●Staff training
●Emergency kit
●Written emergency plan to the clinic
Medical Emergency Management Plan
●Discontinue treatment and assess
consciousness
●Primary survey
●A, B, C, D, E
●Identification and treatment of immediately life
threatening conditions
●Histioy Allergies
Medication
Past medical/surgical history
Last meal
 Initial Management
●Airway
●Breathing
●Circulation
●Disability – Alert
Verbal(Response to verbal command)
Pain(Response to pain)
Unresponsive
●Exposure
 Tenets of Primary Survey
●Proceed rapidly
●Err on the side of aggression
●When in doubt, “do”
●Stay in sequence
●Know what to look for, how to recognise and
how to treat it when present
●Look only for likely, treatable problems
●Use only eyes, ears and stethoscope
●Initiate only simple tests or treatments
 Secondary Survey
●Head to toe region: head, neck ,chest,
abdomen, skeletal, neurological
●Purpose: identification and treatment of
potentially life-threatening problems
●History: data gathering
Find quick sources of information
Interview the family and bystanders
Look over the scene
Check for medical identification bracelet
Call the patient’s physician
 Secondary Survey Cont’d

●System-specific tests and therapy

●Re-evaluation: repeat primary and
secondary surveys until help arrives
●Definitive care: additional care needed to
restore patient to pre-injury or pre-illness
condition
 Compartments of Secondary Survey
Region Common illnesses
● Head Sinusitis, pharyngitis, odontogenic infection, avulsed tooth, facial bone fracture
● Neck Stridor, space infection, hemorrhage with hematoma, neoplasm with airway
compromise, cervical injury
● Chest Angina, myocardial infarction, palpitations, asthma, emphysema, chronic
bronchitis, congestive heart failure, hyperventilation, pneumonia
● Abdomen Acute abdomen
● Skeletal Fracture (fractured hip can result in significant blood loss), dislocation
● Neurological Stroke, seizure, mental status changes secondary to metabolic or
circulatory derangements
 Common Causes of Unconscious
in Dental
● Vasovagal syncope
Surgery
● Cardiac arrest, myocardial infarction and angina
● Airway obstruction
● Drug reactions, allergy and overdose
● Cerebrovascular accident
● Seizures
● Diabetic coma
● Asthma, hyperventilation syndrome
● Acute adrenal insufficiency
● Orthostatic(postural) hypotension
 Vasovagal Syncope

●Temporary loss of consciousness due to

generalised cerebral ischemia

●Precipitated by psychological factors such as

pain or fear

●Usually occur in young fit adults – common in

males
 Vasovagal syncope - Clinical features
Early
● Nausea
● Complaint of warmth
● Perspiration
● Loss of colour
● Tachycardia
Late
● Hypotension
● Bradicardia
● Hyperpnea
● Pupillary dilatation
● Coldness in hands and feet
● Visual disturbances and dizziness
● Loss of consciousness
Patients may get seizures and / or urinate during the syncope
 Vasovagal Syncope
Treatment
● Terminate the procedure
● Tilt the patient to supine or Trendelenburg(legs up) position
● Loosen tight clothing
● Assess consciousness

If the patient not recovered in about five minutes,

another cause of syncope should suspected such as
hypoglycemia ,CVA ,cardiac arrest or hyperventilation
 Postural Hypotention
● Patient become unconscious when resume upright position
● Commonly seen in
Older people
Pregnancy
Addison’s disease
Starvation
Prolonged recumbence
Patients who are on antihypertensive drugs
Management
● Gradual upright of the chair
● Keep the patient sitting in the chair for a few minutes before gets up
 Acute Adrenal Insufficiency
● Cortisol is important to adapt the body to stress
● Can occur in patients with Addison’s disease or on long term steroid therapy
● Clinical features
Lethargy, fatigue and weakness
Hypotension
Loss of consciousness
● Management
Terminate the procedure
Supine position and monitor vital signs
Oxygen therapy
Hydrocortisone 200 mg IV
Call for help
● Prevention
Preoperative steroid cover to the needy patients
 Airway Obstruction
● Can happen with inhaled teeth, equipment or dentures
● In conscious patients they are usually coughed away
● Swallowed sharp objects can cause gastrointestinal tract problems
● Management
If the object can be visualised try to retrieve it
If the patient can breathe they are encouraged to cough
Send the patient for chest/abdomen radiograph
● In complete obstruction
Heimlich maneuver or back blows to dislodge the object
Cricothyrotomy
Call for help
● Prevention
Protect the airway during procedures
Attach threads to the small instruments
 Hyperventilation
●Hyperventilation leads to alkalosis, constriction of the
cerebral blood vessels and loss of consciousness
●Predisposing factors
Anxiety
●Clinical features
Agitated patient starts over breathing
Patients are pink and tachycardic
Loss of consciousness(rare)
●Management
Terminate the procedure
Reassure the patient
Paper bag over the face to re breath expired air
 Asthma
● Stress and some medications can induce an asthmatic attack
● Clinical features
Cough, wheeze and fight for air
● Management
Terminate the procedure
Use “the patient’s own” bronchodilator
Oxygen therapy
● If there is no response
Call for help
IV Hydrocortisone 200 mg.
Adrenaline may be given when unable to breath or does not improve with
bronchodilator
Usual dose 0.5 mg of 1:1000 IM.
 Diabetic Coma
● Hyperglycaemic coma is unlikely at the dental surgery
● Hypoglycaemia can rapidly progress to unconsciousness
● Usually arise if do not eat after anti diabetic medication
● Clinical features
Mood changes
Sweating
Hunger
Confusion
● Management
Stop the procedure
Glucose by mouth to conscious patients
IM Glucagon or IV Dextrose to unconscious patients
Call for help if there is no response
Monitor blood glucose to confirm the diagnosis
 Cerebrovascular Accident(CVA)
● May occur as a transient Ischemic attack(TIA) or CVA
● Clinical features
May be either dramatic with loss of consciousness, slow respiration and
hemi paralysis of the body or
Subtle with no loss of consciousness, minimal impairment of motor or
sensory functions
● Management
Terminate the procedure
Basic life support
Position the patient upright and reassure if conscious
Monitor vital signs
Arrange medical referral
 Seizures(Convulsions)
● Paroxysmal disorder of cerebral function characterised by change in consciousness,
motor activity or sensory phenomenon
● Epilepsy is a term given to a group of disorders can produce seizures due to change
in brain electrical activity
● Other medical emergencies can result in seizures
Vasovagal syncope
Hypoglycemic coma
Cerebrovascular accident
Drug reactions
● Incontinence and biting of the tongue can occur during a seizure
 Seizures(Convulsions)
Management
● Terminate the procedure
● Get the patient away from any risk area to a flat surface
● Gentle restrain to limbs to minimise injury
● Suck out the secretions
● Basic life support
● If the seizure last more than five minutes, call for help and IV diazepam
2mg per minute (Total 10mg)

● Once recovered, patient can be discharge to the care of

a
responsible adult or admit to the hospital in repeated
attacks
 Allergic Reactions
Minor allergic reactions
Urticaria
Pruritus
Angioedema
Erythema
● Anaphylactic reaction
All above as in a minor reaction
Bronchospsam and shortness of breath
Cyanosis
Throat and chest tightness
Altered consciousness
Vascular collapse
Tachycardia and palpitations
Cardiac arrest
 Allergic Reactions
● Usually caused by medications used in dentistry
● Latex allergy
● Commonly seen in females and atopic individuals
● Management of minor allergic reactions
Terminate the procedure
Basic life support
Oxygen as required
Antihistamines(H1 and H2 blocking agents)
● IM or SC Adrenaline may required in severe reactions
● Observe the patient for response
Management of a Anaphylactic Reaction
 Angina Pectoris and Myocardial Infarction
● Retro-sternal crushing pain often radiate to left shoulder or mandible
● Patient may clutch the right hand to chest as they describe the pain(Levine sign)
● Sweating
● Angina is short duration but myocardial infarction pain last longer
● Angina relieved with nitroglycerine but pain in myocardial infarction will not relived
with it
 Angina Pectoris and Myocardial Infarction
● Management
Terminate the procedure
Position the patient upright
Reassure the patient and basic life support
Give nitroglycerine(GTN spray or tablets)
Give oxygen
● If not relived (Myocardial Infarction) call medical help and a ambulance
Use opioid analgesics(Morphine) or N2O/O2 mixture
Give aspirin if not contraindicated
Transport the patient to a hospital
 Cardiac Arrest
●In adults most common cause is ventricular fibrillation
●In children respiratory illness is the most common
cause
●Clinical features
Sudden collapse
No pulse but breathing may present for some time
●Management
In adults
Call for help
Start CPR
In children
Start CPR
 Summary
● Medical emergencies are unpredictable

● Recognise the patients at risk and plan accordingly

● Acquire knowledge and skills to handle emergency

situations

● Make a written emergency plan to your clinic

● Follow the steps of the primary survey to minimized the

morbidity and mortality

Thank you