Medical Emergencies

Basic Principles of Medical Emergency Management

PREVENTION is the most important phase of treating medical emergencies, however despite all efforts at prevention, EMERGENCIES will likely to happen.

THREE STEPS TO PREVENT MEDICAL EMERGENCIES IN THE DENTAL CLINIC:

1. MEDICAL HISTORY
A. Are there any recent changes to health? B. Is the px under the care of a physician? C. Has the px had any serious illness/ operation? D. Is the px taking any drugs/ medications? E. Does the px have any allergies? F. Is the px pregnant?

G. For already diagnosed disorders must ask: 1. When did the px develop the disease? 2. How is the problem controlled? 3. Is there anything that makes the problem worse? 4. Has the px been hospitalized for the problem? 5. Are there any restrictions on the px?

2. PX EVALUATION A. Record vital signs B. Complete dental exam C. Visual inspection of px

Formulate your tx plan at this stage. Determine how this tx plan relates to or is affected by the findings of the medical history & evaluation. Obtain medical consults if needed at this point.

3. STAFF TRAINING AND PREPARATION A. Training: Staff needs to have knowledge to identify and correctly manage each emergency B. Easily accessible emergency equipment and drugs C. Coordination of office personnel

What is adequate preparation?

Guidelines vary, but in general, it is expected that the dentist will be able to initiate emergency mgt. and be capable of sustaining a victims life through the application of Basic Life Support (BLS). ***In times of crisis, simplicity halts confusion.***

BASIC PRINCIPLE OF MANAGING ALL MEDICAL EMERGENCIES

1. BLS: remember ABCs 2. Place the px supine 3. Call for assistance 4. Assure px if conscious 5. Maintain airway 6. Place px on oxygen as indicated by nature of emergency 7. Monitor vital signs 8. Diagnose nature of event 9. Initiate specific tx 10. Document, document, document!

STRESS REDUCTION PROTOCOL FOR THE ANXIOUS PX 1. Recognize pxs anxiety level 2. Consider using pre-medication/ sedation 3. Schedule morning appointments 4. Minimize waiting time and watch appointment length 5. Make sure to use adequate pain control. (varies from px to px) 6. Monitor vital signs 7. Medical consultation if required

Airway Obstruction
General signs and symptoms 1. Gasping of breath 2. Px grabs at throat 3. Panic 4. Suprasternal/supraclavicular retraction If Partial Obstruction - snoring, gurgling, wheezing, growling If Total Obstruction - no noise

Causes of Airway Obstruction 1. Hypo-pharyngeal obstruction (foreign bodies) 2. Blood, water, or saliva in mouth 3. Bronchoconstriction 4. Laryngospasm 5. Tongue (most common)

 Treatment 1. Place px supine on the floor/ 15-300 back in the dental chair 2. Head tilt/chin lift 3. Check airway & breathing, assess cause of obstruction 4. If cause by fluid use suction 5. Consider jaw thrust 6. Reassess airway and breathing 7. If not breathing attempt CPR 8. Reassess airway and breathing 9. If cause by foreign body use HEIMLICH MANEUVER

HEIMLICH MANEUVER/ ABDOMINAL THRUST/ ABDOMINAL HUG

ON ADULT

ON A CHILD

ON INFANT

ON ONESELF

CARDIOPULMONARY RESCUCITATION

Remember the CAB of CPR Circulation: Restore blood circulation with chest compressions Airway: Clear the airway Breathing: Breathe for the person

Airway: Clear the airway

-Open the person's

airway using the head-tilt, chin-lift maneuver. Put your palm on the person's forehead and gently tilt the head back. Then with the other hand, gently lift the chin forward to open the airway.

Breathing: Breathe for the person

Rescue breathing can be mouth-tomouth breathing or mouth-to-nose breathing if the mouth is seriously injured or can't be opened. With the airway open (using the head-tilt, chin-lift maneuver), pinch the nostrils shut for mouth-tomouth breathing and cover the person's mouth with yours, making a seal.

Circulation: Restore blood circulation with chest compressions

 Put the person on his or her back on a firm surface. Kneel next to the person's neck and shoulders. Place the heel of one hand over the center of the person's chest, between the nipples. Place your other hand on top of the first hand. Keep your elbows straight and position your shoulders directly above your hands.

 Use your upper body weight (not just your arms) as you push straight down on (compress) the chest at least 2 inches (approximately 5 cms). Push hard at a rate of about 100 compressions a minute. If you haven't been trained in CPR, continue chest compressions until there are signs of movement or until emergency medical personnel take over. If you have been trained in CPR, go on to checking the airway and rescue breathing.

Hyperventilation
Signs and symptoms:
1. dizziness 2. hard to breathe 3. shaking and trembling 4. cold clammy hands 5. tight feeling in chest, chest pain and palpitations 6. lightheaded 7. uncontrolled over breathing 25-30/min. 8. increase BP and heart rate 9. tingling in hands, feet and perioral areas

Management of Hyperventilation
1. Discontinue tx and remove any foreign objects from the pxs mouth 2. Position px upright 3. Assess airway 4. Reassure px and try to calm them 5. Have px breath slowly and shallowly into a paper bag or mask 6-10x/min. 6.Monitor vital signs 7. Determine what precipitated attack 8. Dismiss px only after vitals signs returned to normal

Allergic Reaction
Signs and symptoms 1. cutaneous rxns. urticaria, itching 2. angioedema (swelling) 3. tightness in chest, sneezing 4. ocular rxns. conjunctivitis, watery-eyes 5. hypotension

 ANAPHYLAXIS severe systemic type of allergic reaction and is a medical emergency

Signs and symptoms:

1. cardiovascular shock including pallor, syncope, palpitations, tachycardia, hypotension, arrythmias, and convulsions 2. respiratory symptoms include sneezing, cough, wheezing, chest tightness, bronchospasm, laryngospasm 3. skin is warm and flushed with itching, urticaria, angioedema 4. nausea, vomitting, abdominal cramps, and diarrhea also possible

Treatment:
General tx: ABCs, maintain airway, administer oxygen, monitor vital signs, and if in shock, put px in a horizontal position or slight Trendelenburg position (head lower than leg position) Mild Reaction: antihistamines usually effective (Benadryl 50-100mg/ Cholpheniramine maleate 4-12mg PO, IV or IM), identify and remove allergen, follow up medication every 4-6hrs. Severe Reaction: call emergency hotline and bring the px to the nearest hospital and observe within 24 hrs.

Asthma Attack
Signs and Symptoms:
1. suffocation 2. chest pressure/tightness 3. non-productive cough 4. wheezes 5. expiration is prolonged than inspiration 6. chest is distended 7. thick stringy mucous

Severe asthma attack

includes: cyanosis of the nail beds, perspiration and flushing of the skin, px may appear confused and agitated, use of accessory muscle for respiration (sternocleidomastoid and shoulder/ abdominal muscles)

Management of an Asthma Attack

1. discontinue dental tx 2. place px in easiest position for them to breath (usually upright with arms outstretched) 3. Albuterol inhaler (Proventil) 2 puffs every 2 mins. 4. supplemental oxygen at 10L/min. if available 5. monitor vital signs 6. if no improvement, call emergency 7. start IV, epinephrine 1:1000 0.3g/20mins. If available

Dental Tx Consideration for the Asthma Px 1. take a good medical history prior to tx determine how often the attack and what precipitates it 2. schedule morning appointments 3. if px uses inhaler they should bring it on hand during tx (consider prophylactic use prior to tx)

Angina Pectoris
Signs and symptoms:
1. substernal pain from chest and radiates to any area above the diaphragm 2. vary form heavy squeezing pain to a heavy pressure on the chest 3. pain usually lasts for few mins. and disappears with rest 4. other symptoms: palpitations, faintness, dizziness, dyspnea, digestive disturbance

Management of Angina Pectoris

1. stop all tx 2. position px upright 3. call emergency 4. administer oxygen if available 5. monitor and record vital signs 6. administer one tablet of Nitroglycerin sublingually 7. if no relief after two mins. Repeat Nitroglycerin (can repeat a third time if no relief but if after the 3rd time still no relief, the px may be suffering from heart attack))

 Dental Consideration for Px with Angina history 1. tx should be oriented towards prevention of angina attack 2. pre-medication of Nitroglycerin sublingually prior to any injection or surgical procedures 3. administer oxygen by nasal canula during procedure 4. consider use of oral/IV sedation to reduce anxiety

Heart Attack (Myocardial Infarction)

Signs and symptoms:
1. preceded by angina 2. heavy, squeezing, pressing or crushing pain in nature (pain located over middle 3rd of sternum) 3. pain radiates to left arm in many cases and can also radiate to the mandible 4. not relieved by Nitroglycerin 5. px express intense fear, restless 6. dyspnea (shortness of breath) 7. Levines sign: px clutch chest with fist

Management of Heart Attack

1. stop all tx 2. clear mouth with any foreign objects 3. place px in an upright position 4. if available administer oxygen 10L15L/min. 5. call emergency, send px to hospital 6. monitor and record vital signs 7. give px Aspirin (325mg.) if available 8. if px loses consciousness, initiate BLS

Syncope (Fainting/Unconsciousness)
Signs and symptoms can be divided into 3 categories: 1. Pre-syncope: warm feeling in face/neck, pale, sweating, feels cold, abdominal discomfort, dizziness, dilated pupil, yawning, fast heart rate, slight decrease in BP 2. Syncope: fainting, generalized muscle relaxation, weak pulse, twitching of hands/legs/face, eyes open 3. Post-syncope: heart rate increases, BP back to normal, mental confusion

Management of Syncope 1. stop all tx 2. remove all objects inside pxs mouth 3. place px in supine position with legs elevated and head at level of heart 3. establish ABC 4. use Ammonia 5. if unconscious for more than 1 min., call emergency

Shock
TYPES 1. Hemorrhagic loss of blood 2. Respiratory insufficient breathing 3. Neurogenic interference with the sympathetic nervous system

4. Psychogenic thought patterns in the brain 5. Cardiogenic inadequate function of the heart 6. Septic cause by bacterial, microbial, or viral infection

7. Anaphylactic allergic reaction (antigenantibody rxn) 8. Metabolic diabetes, low blood sugar, insulin shock 9. Postural sudden change of body position

Management of Hemorrhagic Shock

Mechanical means
1. Application of folded, sterile gauze square compressed over the wound for 20-30 min. 2. Suturing 3. Electric cautery 4. Ligation of vessel

COMMONLY USED HEMOSTATIC DRUGS IN DENTISTRY

1. Monsels solution 2. Thrombin 3. Tannic acid 4. Gel foam 5. Oxygel 6. Surgicel

HEMOSTATIC DRUGS
1. COAGULANT- promotes blood clotting 2. ASTRINGENT- applied topically causing capillaries to contract 3. EPINEPHRINE- controls minor bleeding

Management of Postural Shock

1. Immediately reposition the px in a supine position 2. If the px is unconscious and does not revive,tilt his head back (chin up) and check his breathing. If not normal, do triple airway check 3. Slowly return the px in an upright position. If he feels dizzy and faint, lower him to the supine position at once.

Management of Anaphylactic Shock

1. Anti-histamine 2. Epinephrine 1:1000 in a dosage of .5 ml subcutaneously in the arm or thigh. If severe, additional dose after 10 minutes 3. Oxygen to relieve patients distress along with anti histamine

Management of Cardiogenic Shock

1. Let px sit upright at a 45 degree angle 2. Give oxygen and call emergency

Management of Psychogenic Shock

1. Lower the px to a supine position. 2. Pxs feet should be elevated to a position higher than his head to cause the blood to flow towards the brain (Trendelenberg position)

3. An ampoule of spirits of ammonia may be fractured in a gauze square and wafted gently under the patients nostrils.
4. The PR and the BP should be taken and recorded for the dentist to interpret. Usually px regains consciousness within 1 to 2 minutes.

Epilepsy
Classification:
1. Petit mal
-mild

and brief in duration, few seconds -px may seem to be staring into space

2. Grand mal -severe with loss of consciousness, followed by violent contraction of the muscles -may last several minutes

Management of Epilepsy
1. Protect the px from self injury 2. Heavily padded tongue depressor or folded towel should be placed between the pxs teeth to prevent tongue biting

3. Attempt to maintain a free airway for the px but do not put your fingers in the pxs mouth

NOTE:
OVERFATIGUE AND ANXIETY TRIGGERS SEIZURE - Epileptic pxs should be scheduled for tx early in the day

STROKE
also known as a cerebrovascular accident (CVA) It is the rapid loss of brain function due to disturbance in the blood supply to the brain. This can be due to ischemia (lack of blood flow) caused by blockage (thrombosis, arterial embolism), or a hemorrhage (leakage of blood

Signs and symptoms

Smoothing out of forehead Eyebrow droop Drooping of the corner of the mouth

Classification of stroke
1. Ischemic - occur as a result of an obstruction within a blood vessel supplying blood to the brain. The underlying condition for this type of obstruction is the development of fatty deposits lining the vessel walls. 2. Hemorrhagic - It results from a weakened vessel that ruptures and bleeds into the surrounding brain. The blood accumulates and compresses the surrounding brain tissue.

Risk factors of stroke Over age 55 More common in males African American, Hispanic or Asian/Pacific Islander A family history of stroke High blood pressure

High cholesterol Smoking cigarettes Diabetes Obesity and overweight Cardiovascular disease A previous stroke or transient ischemic attack (TIA) High levels of homocysteine (an amino acid in blood) Birth control use or other hormone therapy Cocaine use Heavy use of alcohol

DENTAL MANAGEMENT OF THE STROKE PATIENT

A patient with stroke in his record shall get special care during dental treatment: appointments shall be for choice in the morning, shall be short and without stress. Clinical approach shall take into consideration in several aspects:
Disabled patients shall be helped by the nurse to sit on dental chair, their airways shall be free and they shall be accompanied by the persons taking care of them, especially if speech difficulties are present

DENTAL MANAGEMENT OF THE STROKE PATIENT

Anamnesis shall be simple and optimistic, dentist shall stand in front of the patient, without mask, shall look him in the eyes, shall move slowly and questions shall be simple and clear, for plain answers (yes/no) Anamnesis should reveal patients risk factors: if the medical record shows high blood pressure, cardiac diseases, transient vascular accidents, diabetes, heavy smoking, old age, then such a patient is prone to stroke and/or myocardial infarction. History of past strokes needs to be elicited: date, seriousness, treatment, disabilities. There are situations when patients speech is not affected, but he cannot realize the extent of the palsy (he is not aware of it) or situations when a patient with brain injury on his right side is neglecting his left side of the body

DENTAL MANAGEMENT OF THE STROKE PATIENT

Blood pressure and pain should be monitored and under control during the entire intervention Emergency dental treatment is allowed six months after stroke, it should be performed carefully, by neurologists advice and some precautions are needed, according to the specific characters of the stroke

DENTAL MANAGEMENT OF THE STROKE PATIENT

If needed, dental treatment produces bleeding (teeth extraction, pulpectomy, subgingival scaling, periodontal surgery), anticoagulant systemic medication may cause serious hemorrhage, therefore anticoagulant drugs like heparin should be stopped at least 6-12 hours before treatment. Six hours after bleeding, when blood clots are built up, heparin systemic treatment can be resumed. If there is some other anticoagulant medication involved, it should be stopped several hours or days before bleeding dental treatment, after determining the International Clotting Rate (ICR) and decision depends on neurologists advice

 The dentist should be ready for emergency intervention in case of local hemorrhage, with haemostatic medication and cautery, blood pressure should be monitored and oxygen therapy device is needed in dental office

 The minimal amount of anesthetic solutions should be injected, concentration of added epinephrine should be very low (1:100.000 or 1:200.000). Use of gingival retraction cord soaked with epinephrine should be avoided. Metronidazolum and tetracycline should be avoided, since they may affect blood clotting. If the patient shows symptoms of stroke, he should get oxygen therapy immediately and should be referred to a hospital as soon as possible.

DENTAL MANAGEMENT OF THE STROKE PATIENT

DENTAL MANAGEMENT OF THE STROKE PATIENT

If patients show minor physical disabilities after stroke, they can present poor oral hygiene. For such patients, dentists will advise the use of electric toothbrushes, easier to handle, use of dental floss, oral irrigation and prophylaxis using chlorhexydine and fluoride.

 Patients with speech and deglutition disabilities due to paralysis of oro-facial muscles, with loss of sensitivity of the tissues, with flaccid, multiple pleated and possibly asymmetrically positioned tongue, with dysphagia, may present accumulation of food residues on teeth, tongue, oral mucosa. They must learn to clean their teeth and oral cavity using only one hand or to get/accept another persons help, in order to avoid caries, periodontitis, halitosis or oral mucosa diseases.

DENTAL MANAGEMENT OF THE STROKE PATIENT

Edentulous patients are advised to get fixed prosthodontic treatment, because of the difficulties of insertion and removal of removable dentures.