Medical emrgencies in dental practice
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Transcript of Medical emrgencies in dental practice
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Medical Emergenciesin
Dental Practice
Prepared by: Dr . Aia Al-Marsumy
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What is an Emergency situations? Common Emergency Situations are
Fainting (Vasovagal Syncope )Diabetic ComaAnaphylactic ShockEpileptic SeizuresCardiovascular Collapse (CVC)Thyroid CrisesAdrenal CrisesAsthmatic AttackStroke (Cerebro-vascular Accident, CVA
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emergencies: Clinical Presentation of
-Sudden loss of consciousness
-Chest pain & dyspnea
-Convulsions (fits)
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Basic Emergency Procedures - Monitor BP and pulse
Clear, secure & maintain Airway cardiopulmonary resuscitation
intravenous cannulation ↓
Basic Life Support (BLS) A- Airway
B- Breathing C- Circulation
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Collapse
• shock• Steroid crisis• Myocardial Infarction• Cardiac Arrest• CVA
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Acute Chest Pain or Difficulty ofBreathing
Angina
Myocardial Infarction
Asthma
Anaphylactic Shock
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ConvulsionsEpilepsy
Any other cause of loss of consciousness
including fainting
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Fainting
•Predisposing factors:
Stress Conditions AnxietyPain
InjectionFatigueHunger
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Pathophysiology
Stress↓
Release of catecholamine↓Changes in tissue blood perfusion; decreased peripheral vascular resistance, increasedblood flow to tissues↓leads to pooling of blood in tissue
↓fainting
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Mechanism
• Signs & Symptoms Premonitory dizziness, weakness & nausea
Pale, cold moist skin
Pulse initially
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Management
•Lay flat & lift legs
•Loosen tight clothing around neck
»Give sweetened drink on regainingconsciousness
•Prolonged fainting, atropine 600 mcg/ml slow iv (1 ml only)
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prevention• Good history
• Reassurance
• General Anxiety (Stress) Reduction Protocol
• Well fed prior to treatment
• Glucose drink
10 mg Temazepam nocte (prior to appt) & 1hour before treatment
• Delay the procedure
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Anaphylactic shock• Drugs e.g. penicillin
• Insect stings
• Foods, nuts, shellfish, materials
Quicker onset the more severe the reaction
• Widespread vasodilatation & increase incapillary permeability, potentially fatal
• Hypotension
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Hypersensitivity Type I
-Immediate -IgE mediated
-Anaphylaxis -Urticaria
-Angio-oedema -Allergic Asthma
-Rhinitis
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Adverse Reactions
• Hypersensitivity
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• Angio-oedema
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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
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Management of Anaphylaxis•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
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Accidental swallowing of foreign bodies
• A case of swallowed dental root canal instrumentEsophagogastroduodenoscopy
•needle-like foreign body sticking deep in the duodenal wall
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• the object was removed by forceful extraction with a rat tooth forceps and identified as a dental root canal instrument, distinctly changed by gastric acid.
Extracted instrument
Original instrument
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• The patient then remembered that the pain was started after a dental root canal treatment under local anesthetics.
• The pain was probably due to the irritation of the duodenal wall by needle while moving the upper part of the body during ironing.
• Generally foreign bodies passes through the gastro intestinal tract within 1 week, but might get stuck especially when sharp.
• Earliest symptom is dysphagia.
• An ingestion of such an instrument is extremely rare i.e. 0.12/100,000 root canal treatments.
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A case of swallowed Dental Prosthesis
• Plain abdominal radiograph
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• The Endoscopic view shows the extraction from jejunum to the mouth, here the image shows that foreign body is at the esophagus.
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Extracted Prosthesis• The prosthesis was a successfully managed
endoscopically.
• Observe at the right of • the dental bridge has a sharp edge.
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Acute Hypoglycemia
Causes : Overdose of insulin Prevented from eatingat expected time
• MANAGEMENT:• Glucose tablets/powder• If unconscious give• 50ml 50% glucose IVSC glucagon 1mg
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The Diabetic Patient Hyperglycemia Hypoglycemia
Slow onset Rapid onset
Dry skin & mouth Moist skin
Pulse slow & weak Pulse full & rapid
Drowsiness/disorientation Irritability
Rare More common
more Severe Less Severe
Difficult to be managed Easy to be managed
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THYROID CRISIS (STORM)Sudden, Severe Exacerbation of Hyperthyroidism
• Precipitating Factors:• Infection
• Surgery
• Trauma
Pregnancy
• Other Physiologic or Emotional Stress
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Manifestations:•
• Hyperpyrexia (Fever)
• Tachycardia
• Agitation
• Palpitation
• Nausia, Vomiting
• Abdominal pain
• Loss of• Consciousness• (Partial or Complete)
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Management• Terminate all dental ttt• • Summon medical assist• • Administer O2• • Monitor VS• • Initiate BLS, if necessary• • Start IV line & Fluids• • Transport to ER Care
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STEROID CRISISCirculatory Collapse
The Pt ProblemAdrenocortical Insufficiency:Primary(Addison`s Disease);RareSecondary(Exogenous);more common (20mgcortisoldaily/2weeks/year)
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• CAUSES: Stress Conditions• GA• Surgical/Other trauma• Infection• Other stress• SIGNS & SYMPTOMS• Pallor• Weakness• Nausea• Rapid, weak or• impalpable pulse• Loss of consciousness• Rapidly falling BP
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• 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
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ASTHMA
• Causes• Anxiety• Infection or exposure to• specific allergen• Loss or forgetting to bring• Salbutamol inhaler
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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
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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 500mcg i.m/s.c., CALL AN• AMBULANCE
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Angina• Signs & Symptoms• Acute chest pain which may• radiate to left arm or shoulder• Relieved by anti anginal druge.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
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Myocardial InfarctionSigns & Symptoms• 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
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Management• Place patient in a comfortable position• allowing easy breathing• Send for an ambulance• Give 50/50 Nitrous Oxide/Oxygen or Oxygenonly• Aspirin 300mg• Good pain control• Constant reassurance
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Cardiac Arrest• Causes
• Myocardial Infarction• Hypoxia• Anaesthetic overdose• Anaphylaxis• Severe hypotension
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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
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• Chain of Survival
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Stroke (CVA)• Signs ,Symptoms & management• 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
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CONVULSIONS (Epilepsy)Grand mal, Petit mal (blank stare)
• Predisposing factors:• Anxiety• Hunger• Menstruation• Alcohol• External stimuli, flashing lights etc• Non compliance with medication
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Convulsion•Signs & symptoms
•Grand mal
•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
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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
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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
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The Recovery Position
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Emergency Kit• Telephone • Oxygen cylinder• • Laerdal pocket• mask/Ambubag for hand• ventilation• • Disposable airway• (Sizes1-4) Guedel• • Disposable syringes• (2,5,50 ml)
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• Disposable needles (23g)• • Tourniquet• • Cannulae (20g)• • Portable suction• equipment
•• Sphygmomanometer/• automatic BP machine• • Pulse oximeter
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• 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%
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Be Prepared • Adequate training
• Protocols• Medical history• Prevention• Checks& Updating
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Reference
• Medical emergency in dental office DCNA july• 199• 5 by JEFFERY D BENNETT• • Medical emergency in dental office : Malamed• 6• th• edition• • Text book of oral surgery by Bala JI
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THANK YOU