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
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 limits 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
a. Medication
b. Past medical/surgical history
c. Last meal
d. Event surrounding the emergency
6.
Resuscitation
Initial Management
- Airway
- Breathing
- Circulation
- Disability – Alert
o Verbal(Response to verbal command)
o Pain(Response to pain)
o Unresponsive
·
Exposure
·
(A,B,C, Don’t Ever Forget Glucose)
Tenets of Primary Survey
o Proceed rapidly
o Err on the side of aggression
o When in doubt, “do”
o Stay in sequence
o Know what to look for, how to
recognise and how to treat it when present
o Look only for likely,
treatable problems
o Use only eyes, ears and
stethoscope
o 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
o
Find quick sources of
information
o
Interview the family and
bystanders
o
Look over the scene
o
Check for medical
identification bracelet
o
Call the patient’s physician
·
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, haemorrhage with haematoma, 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 Surgery
- Vasovagal syncope
- 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
1.
Terminate the procedure
2.
Tilt the patient to supine or Trendelenburg(legs up) position
3.
Loosen tight clothing
4.
Assess consciousness
5.
If the patient not recovered in about five minutes,
6.
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
1. Gradual upright of the chair
2. 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
·
Anxiolytic therapy
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
i. Terminate the procedure
ii. Basic life support
iii. Position the patient upright and reassure if
conscious
iv. Monitor vital signs
v. 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
1.
Vasovagal syncope
2.
Hypoglycemic coma
3.
Cerebrovascular accident
4.
Drug reactions
Incontinence and
biting of the tongue can occur during a seizure
Management
1. Terminate the procedure
2. Get the patient away from any risk area to a flat surface
3. Gentle restrain to limbs to minimise injury
4. Suck out the secretions
5. Basic life support
6. If the seizure last more than five minutes, call for help and IV
diazepam 2mg per minute (Total 10mg)
7. 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
- Call for help
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”
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