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 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
  1. Discontinue treatment and assess consciousness
  2. Primary survey
  3. A, B, C, D, E
  4. Identification and treatment of immediately life threatening conditions
  5. 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
  1. Vasovagal syncope
  2. Cardiac arrest, myocardial infarction and angina
  3. Airway obstruction
  4. Drug reactions, allergy and overdose
  5. Cerebrovascular accident
  6. Seizures
  7. Diabetic coma
  8. Asthma, hyperventilation syndrome
  9. Acute adrenal insufficiency
  10. 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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