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EMERGENCIES IN DENTAL PRACTICE

Emergency in dental office are usually rare encounters since the practioners potential
problems and manage them before because of an emergency.

According to a study by Melamed revealed that hyperventilation ,seizures and hypo


glycemia were the three most common emergencies before ,during or soon after being on
the dental chair.

Incidence of a medical emergency is seen mostly during or before a surgical care because
of three factors namely ;

1. Surgeries stress provoking.


2. Greater number of medication is administered.
3. Longer appointment.

Prevention of medical emergency is the corner stone of their management.

Step One: Risk management

Medical evaluation(history)

Vital signs recorded

Physical examination

Step Two: Prevention is the best thing after prevention, deal with the management
of medical emergency.

Understand emergency problem

Early recognition of the condition

Start management as soon as the condition is recognized

Call to the physician immediately.

Make patient lie down supine position with head low and tilted to one side

Maintenance of patent airway, breathing, circulation

Oxygen may be administered in life threatening emergencies

Vital signs to be monitored


Syncope
It is a transient loss of consciousness due to cerebral anoxia .

It is also called fainting, common fainting attack or vasovagal attack.

Generally occur because of series of cardio vascular event triggered by emotion


stress brought by the anticipation of being delivered dental procedures.

Other factors be anxiety ,fear, sight of blood , pain, extortion, fasting and hot
environment

These emotional stress release increase amount of catecholamines.

Pt complaints of being dizzy /weak, compensatory mechanism attempt to maintain


adequate blood pressure but soon fatigue and lead to vagally mediated bradycardia.

If severe, may lead to seizures.

Signs and Symptoms


Patient feels weakness warmth,nausea and pain in epigastrium and hunger before
fainting. After this sweating dizzness pallor, light headedness and low pulse pressure
develops.

If treatment is not instituted patient develops unconsciousness, ashen grey color of skin,
shallow respiration, decreased blood pressure weak pulse ,standing patient falls; may
develop clonic jerks and twitching of facial muscles.

Management

1. Terminate the dental treatment.


2. Position patient in supine posture with legs raised above level of head.
3. Attempt to calm the patient.
4. Keep a cool towel on the forehead.
5. Monitor vital signs.
6. Tight clothing should be loosen.
7. Check for breathing.

If absent

a. Start basic life support.


b. Medial assistance.
c. Consider causes of syncope , hypoglycemia , cerebralvascular
accident, cardiac dysrhythma

If present

a. Crush ammonia ampule under the patient nose.


b. Admister oxygen.
c. Vital signs to be recorded.
d. Escort patient to his room.

Later,if the above doesn’t show results- 100% oxygen

Bradycardia - __ atroprine 0.6mg dilute in 5ml of diluted water

If hypotension is presents – vasopressor drugs

Phenylephrine/methoxamine

Prevention is the best way to treat syncope.

1. Carry out dental proceed in semi-reclining position.


2. Dentist should develop good rapport with patient to allay fears.
3. Patient should be neither fasting nor full stomach.

2. SHOCK

Clinical phenomenon marketed by circulatory deficiency which is either cardiac or


vasomotor in origin exhibiting marked hypotension.

Prime Shock is also called syncope which is not tackled and if persists then secondary
appears.

Seen on account of :
1. Haemorrhagic shock – due to massive loss of internal bleeding.
2. Hypovolumic Shock – due to fluid loss

Eg. Seen in diarrhoea, dehydration

3. Cardiogenic Shock – because of cardiac ailment.


4. Septic Shock – due to toxemia.
5. Anaphylactic Shock – during reaction
6. Neurogenic Shock – following syncope
7. Misc Shocks – hypo/hyper glycemia or adrenal insufficiency

Disparity between the circulating blood volume of the body and the volume capacity of
the vascular tree

This disparity is called cerebral ischemia.

Signs and Symptoms

• Unconsciousness
• Ashen grey face
• Cold Clamming skin
• Lips, nails, lobule of ear – grayish blue
• Face expression – sunken eyes
• Pupils decaled
• Weak pulse
• Respiration shallow ,irregular ,rapid
• Temperature – subnormal
• Shock can be more easily prevented then treated.

Allergic Reaction
Allergy/hypersensitivity is an unwanted response of the body to a complete dose of the
drug. It is as a result if an immunological response by the individual who has become
sensitized to the drug through a prior exposure.

It is an antigen-antibody reaction where the drugs behave as antigens by joining with


tissue proteins/ polypeptides.

Signs and Symptoms

The least severe manifestation is dermatologic lesions ;which include


uticaria,erythema,maculopapular or nodlar rash,petechial haemorrhages

Allergic reaction affecting the resp track are more serious.They manifest as angioedema
of tongue,eyelids,larynx and bronchi. In case of more severe reaction,patient may
complain of dyspnoea,wheezing,bronchospasm and many become cyanotic. Patients
unable to speak produces stridors.

Treatment

• Patient is ( is trendlenberg position) with head lover than feet


• Maintain body heat by covering patient with blanket or hot water bottle
• Patient _____
• Control of loss of blood - pressure packs etc
• Restore body fluids
• 100% oxygen – ad___eslened
• Vital aigns should be _____orced – BP,resperate,pulse
• Using hydro____ - 100mg dis in ____ H2O
• Using mephentismine – hypoti____
• Atropine – pulse/ weak
• Broad space antibiotics – 1/V

Respiratory Emergencies

1. Hyperventilation

Denotes increase in alveolar ventilations disturbing the optimum levels of O2 and


CO2. It is caused by abnormally rapid and deep breathing leading to respiratory
alkalosis.

It is often precipitated by anxiety, fear, nervousness and emotional stress etc.


Commonly seen in females . Results in lowered level of CO2 in the blood or
hypocapnoea and causes reduction in cerebral blood flow, decrease in peripheral
resistance leading to hypotension which further leads to decrease in ionized Ca
level in the blood followed by tetanic spasms

Signs and Symptoms

Dizziness, difficulty in breathing, palpitation, tingling sensation of fingers tips


and toes,pain in chest, carpopedal spasm of tetany ,mental confusion , fatigue ,
loss of consciousness.

Reactions

1. Terminate dental procedures and remove foreign body from mouth.


2. Position patient in upright position
3. Verbally calm the patient
4. Make patient breathe Co2 enriched air
5. If symptoms worsen : Diasepam – 10mg 1/m or 1/v

Midosolam – 4-5mg 1/m

6. Monitor vital signs


7. Perform further dental surgery using anxiety – reducing measures

Manifestation

1. Delayed onset s___ signs ,erythema,_____ oerritis,anzioedema

Management

o Stop administration of all drugs.


o Administration im/iv benadryle 500mg or chlor-trimeton 10mg
o Refer physician
o Oral antihistaminic

Manifestation

2. Immediate onset s___ s___ ,erythema,urticaria, p____,anz___dima

Management

o Stop adimn of all drugs


o Admis ep___phrine 0.3ml of 1:10000 1m/1v
o Repeat after 5mm
o Ademin 1m/1v
o Antihist
o Monitor vital signs frequency
o Consult physician
o Observe for 1hr
o Prescribe oral anti- histaminic
Manifestation

3. Respiratory signs with .without sking signs ____ing mild ___pnea

Management

• Stop adimin of all drugs


• Place in the sitting position
• Admen of epinephrinc
• Give oxygen 6/min by face mask/nasally
• Monitor vital signs
• Admen antihistaminic
• Provide 1v access
• Consult physician
• Observe for 1hr
• Prescribe antihistaminic

Manifestation

4. Stridorons brailing(crowning sound) moderate to severe dygshea

Management

• Top admen of drugs


• Sit in upright position
• Call for medical assist
• Ademin epi____phrine
• Give oxygen
• Vital signs
• Aol___ anti histaminic
• Provide 1v assess – if signs worry

Manifestation

5.Anaphylane is with or without skin signs – malaise wheezing ,mod- se-dysnea


slendor ,cyanosis ,total airway obs, nausea and vomiting ,abd cramps,_____
inconlenence, tachycardia, hypotension, cardiac dysrlytheias, cardiac arrest

Management

o Stop admin od all drugs


o Position patient’s supine on back board/on floor and summon
assistance
o Admin epine phrine initiate BLS
o Vetal signs
o Consider criothyrodonty
o Give oxygen
o Anolm of sntihist 1/v or 1/m
o Prepare for transport

Siezures
Management – Terminate Dent. Procedure

Patient Position – supine with legs elevated medical assistance  protect patient from
injury  basic life support  oxygen  monitor vital signs

Drugs of voice Diazepam 10mg rate – 5mg/min

Repeat every 10mins

Children – 0-3mg/kg

Unconscious Patient

Patient Position – horizontal supine  rain-heart same level feet elevated 10-15
degrees  head down

Pregnant – on right

on left  pillows etc

patient venous return

Adrenal Insufficiency
Patient who are on long term contrcosleroids for reaction of a variely of syscenue cored
develop adrenal suppression

If any patient is under stress the adrenal suppression prevents the normal release of
glucocorticoids from the adrenal cortex. This is because of fall in production of ACTM
secreted by anterior in response to the steroids ademin to the patient to the point . ACTM
in turn controls the production of corticoids in the adrenal cortex.

Management

• Terminate all dental Rx


• Position patient in supine position with legs raised above normal level of
head
• Medical assistance
• Admn of corticosleroid (___ing of hydrocorlesose)
• Adimin oxygen
• Vital signs
• 1/v drip crystalloid solution
• BLS
• Emergency

Pregnancy

A resp to em and pl___ stress of Px large quantity of steroids are liberated into the
blood stream .It secretes oxcylocim and lead to premature labour

A patient is ____/_____ position can h___ pressure on __ venacave by the


fractures leading to poor ___ return and hypolensurs .

Turning patient onto the side will relieve the patient pressure and put the back to
the normal.

A patient supine hypolensron syndrome should be turned to left side in the


reclining position and constantly reassured for a quick recovery.

Asllrune

Patient with H/O assllrune can be particularly challenge to manage safely.It may
trigger due to em. Stress or any pharma agents.The signal of onset is
Bronchospasm

Patient complains of :

o Shortness of breadth
o Sit erect(patients wants to)
o Wheezing in audible
o tachypnea

may become : cyanolic

hypoxic

and loss of consciousness

Management

o terminate treatment
o repos- patients in sitting posture
o admin broncho_____ (___)
o admin oxygen
o monitor vital stats

if reduced : refer physician

if symptoms continue :

 ep____ - 0.3ml
1:10000

1m SC 1v

 1/vdring crystalloid
solution
 If vital signs reduce
then refer physician
 If symptoms correct
 medical assistment
theoplylin 1/v 250mg &
corlisone 100mg 1/v 
emergency

Chest Discomfort
The app of chest discomfort is a patient who ___ __ is chaemic heart disease in the peri
uperentive period caleis

Clinical Features

• Discomfort  pain, sneezing ,brushing ,pressing, burning, choking


• Subslirnarly located, may be radiated to left shoulder or left side neck or
mandible .
• Ass with exertion,heave metal ,anxiety etc
• __ by vasodilators - ____ cernine etc
• A_____ by dyspnea ,nausea, weakness, palpitations

Treatment

Position patient in semi reclurring posture

Give nitrogycerine (TNG) 0.4mg tab or spray

Admin oxygen

Check pulse and blood pressure

If:

Continuous(3mins)  2nd dose TNG,moniter vital stats  if not relieved, 3rd dose
,moniter vital stats  if not relieved  discomfort continuous then :

1. assume MI in
progress
2. S_____ medical
assistance
3. 1/v drip crystalloid
sol. 30min/hr
4. Morphine Sulfate
5. Transport for
Emmergency

Diabetes

Two types of problems are with diabetes


• Hypoglycemia/insulin shock
• Diabetic coma/keroacedosis/hyper glycerin

Hypoglycemia is seen frequently

Manifestation

Mild Moderate Severe

• Hunger tachycardia hypotension


• Nausea perspiration unconsciousness
• Mood change pallor siesures
• Weakness behavior change

Management

Terminate Dental Procedures

Mild Moderate Severe

o Admen glucose G admen 50ml of 50%

source fruit juice G 1/v or 1mg glucagons

o Monitor vital stats Admen 50ml of 50% Medical


assistance

G or 1mg

o Consult physician glucagons 1v or 1m Admen


oxygen