Management of medical emergencies in the dental practice

1. 1 MANAGEMENT OF MEDICAL EMERGENCIES IN DENTAL PRACTICE - 60

2. MANAGEMENT OF MEDICAL EMERGENCIES IN DENTAL PRACTICE Presented by: Dr.Kanika Manral 2 MANAGEMENT OF MEDICAL EMERGENCIES IN DENTAL PRACTICE - 60

3. CONTENTS Introduction Types of emergencies Prevention Preparation Management Summary Conclusion References 3 MANAGEMENT OF MEDICAL EMERGENCIES IN DENTAL PRACTICE - 60

4. INTRODUCTION 4 MANAGEMENT OF MEDICAL EMERGENCIES IN DENTAL PRACTICE - 60

5. STRESS!! SYNCOPE SEIZURE ANGINA ASTHMATIC ATTACK HYPOGLYCAEMIA CARDIAC ARREST ALLERGIES HYPERVENTILATION MYOCARDIAL INFARCTION 58% 42% 5 MANAGEMENT OF MEDICAL EMERGENCIES IN DENTAL PRACTICE - 60

6. Comprehensive medical history Vigilant observation & prompt recognition of symptoms of an emergency Basic life support Affiliation to definitive medical care 6 MANAGEMENT OF MEDICAL EMERGENCIES IN DENTAL PRACTICE - 60

7. COMPREHENSIVE MEDICAL HISTORY Thorough questionnaire Past medical history Familial disease history Psychological/ social status Diet 7 MANAGEMENT OF MEDICAL EMERGENCIES IN DENTAL PRACTICE - 60

8. BASIC LIFE SUPPORT Primary response to all emergencies. P-A-B-C-D Position>Airway>Breathing>Circulation>Defibrillation(ACLS) BLS 8 MANAGEMENT OF MEDICAL EMERGENCIES IN DENTAL PRACTICE - 60

9. ASA PHYSICAL STATUS CLASSIFICATION CLASS I: Healthy patient with no systemic disease. CLASS II: Patient with mild systemic disease with no limits on activity. CLASS III: Patient with severe systemic disease that limits activity. CLASS IV: Patient with incapacitating systemic disease that is life threatening. CLASS V: Terminal moribund patient. 9 MANAGEMENT OF MEDICAL EMERGENCIES IN DENTAL PRACTICE - 60

10. TYPES OF EMERGENCIES UNCONSCIOUSNESS / SYNCOPE Vasodepressor Syncope Postural/Orthostatic Hypotension Acute Adrenal Insufficiency Hypoglycemia SEIZURES RESPIRATORY EMERGENCIES Airway Obstruction Hyperventilation Asthma Contd … 10 MANAGEMENT OF MEDICAL EMERGENCIES IN DENTAL PRACTICE - 60

11. CARDIOVASCULAR EMERGENCIES Angina Pectoris Myocardial Infarction DRUG RELATED EMERGENCIES Overdose Reactions Allergies FUNCTIONAL EMERGENCIES Needle Stick Injury Needle Breakage 11 MANAGEMENT OF MEDICAL EMERGENCIES IN DENTAL PRACTICE - 60

12. UNCONSCIOUSNESS / SYNCOPE “Sudden transient loss of consciousness  in which one shows no responsiveness to non-deliberate environmental stimuli” Predisposing factors: STRESS IMPAIRED PHYSICAL CONDITION HYPOGLYCEMIA Webster-Merriam’s Medical Dictionary. 12 th ed. Baltimore:Williams;2011.“syncope”;p.348 12 MANAGEMENT OF MEDICAL EMERGENCIES IN DENTAL PRACTICE - 60

13. PREVENTION Via prevention of predisposing factors: Use of psychosedative drugs ingestion- alprazolam (4mg), diazepam(5mg) i.m / i.v administration- butorphenol (1mg), midazolam (5mg) inhalation-N 2 O+O 2 (15%+85%) Persuasion/Hypnosis 13 MANAGEMENT OF MEDICAL EMERGENCIES IN DENTAL PRACTICE - 60

14. VASODEPRESSOR SYNCOPE 14 MANAGEMENT OF MEDICAL EMERGENCIES IN DENTAL PRACTICE - 60

15. POSTURAL /ORTHOSTATIC HYPOTENSION PATHOLOGY Drugs Prolonged recumbency / convalescence Late stage pregnancy Varicosities Addison’s Disease Severe exhaustion Shy- Drager Syndrome ETIOLOGY 15 MANAGEMENT OF MEDICAL EMERGENCIES IN DENTAL PRACTICE - 60

16. ACUTE ADRENAL INSUFFICIENCY Syncope caused due to lack of an adrenaline response in medullary deficient patients resulting from:- 16 MANAGEMENT OF MEDICAL EMERGENCIES IN DENTAL PRACTICE - 60

17. HYPOGLYCEMIA 17 MANAGEMENT OF MEDICAL EMERGENCIES IN DENTAL PRACTICE - 60

18. MANAGEMENT OF SYNCOPE Treat the underlying cause Immediate symptomatic therapy includes: Recognition of unconsciousness “Shake & shout” Check for protective reflexes Management Position victim- supination Assess & open airway-head tilt, chin lift Airway patency, breathing, circulation-look, listen & feel Artificial ventilation & cardiac massage-cardiopulmonary resuscitation BLS 18 MANAGEMENT OF MEDICAL EMERGENCIES IN DENTAL PRACTICE - 60

19. BASIC LIFE SUPPORT 19 MANAGEMENT OF MEDICAL EMERGENCIES IN DENTAL PRACTICE - 60

20. SEIZURES EPILEPSY- “A chronic brain disorder of various etiologies characterized by recurrent seizures due to excessive neuronal discharge” SEIZURE/ICTUS- “A paroxysmal disorder of cerebral function characterized by a short attack involving changes in the state of consciousness, motor activity, or sensory phenomena” TONUS- “Neuromuscular dysfunction characterised by sustained contraction and tonicity of all striated muscles” Webster-Merriam’s Medical Dictionary. 12 th ed. Baltimore:Williams;2011. “Epilepsy”, “Seizure”, “Tonus”; p166,327,428 20 MANAGEMENT OF MEDICAL EMERGENCIES IN DENTAL PRACTICE - 60

21. CLONUS- “An abnormality in neuromuscular activity characterized by rapidly alternating muscular contraction and relaxation” POST-ICTAL PHASE- “A phase of centralised neuronal depression following a clonic seizure in which the subject demonstrates generalised muscular relaxation observable as deep slumber” STATUS EPILEPTICUS- “A prolonged repetitive seizure with no recovery between attacks leading to a life-threatening emergency situation” Webster-Merriam’s Medical Dictionary. 12 th ed. Baltimore:Williams;2011.“ Clonus ”, “Post- Ictal Phase”, “Status Epilepticus ”; p98,279,369 21 MANAGEMENT OF MEDICAL EMERGENCIES IN DENTAL PRACTICE - 60

22. ASA CLASSIFICATION OF EPILEPTIC SEIZURES TYPE I-Absence Seizures/Petit Mal Epilepsy TYPE II- Myoclonic Seizures TYPE III- Clonic Seizures TYPE IV-Tonic Seizures TYPE V-Tonic- Clonic Seizures/Grand Mal Epilepsy TYPE-VI- Atonic Seizures 78% 11% 3% 4.8% 1% 2.2% 22 MANAGEMENT OF MEDICAL EMERGENCIES IN DENTAL PRACTICE - 60

23. PREVENTION If pt is a known epileptic, make sure he/she has taken their regular dose of anti- convulsant on the day of appointment. Instruct him/her to alert you as the aura of the impending seizure manifests itself. Inhalational sedation, based on individualised severity levels. Keep life support equipment ready in case of an emergent status epilepticus . 23 MANAGEMENT OF MEDICAL EMERGENCIES IN DENTAL PRACTICE - 60

24. MANAGEMENT Self limiting emergency Remove dangerous objects from the mouth and around the pt.eg. sharp instruments, needles, etc. Loosen any tight clothing. Avoid restraining the pt. In case the ictus fails to subside within a maximum of 10 minutes, declare status epilepticus and proceed with BLS + definitive care. 24 MANAGEMENT OF MEDICAL EMERGENCIES IN DENTAL PRACTICE - 60

25. RESPIRATORY EMERGENCIES 25 MANAGEMENT OF MEDICAL EMERGENCIES IN DENTAL PRACTICE - 60

26. AIRWAY OBSTRUCTION May occur due to: Pathology in the airway Dental instruments Tongue Patient demonstrates symptoms ranging from coughing, gurgling, gagging to choking & gasping with panic. Aspired object may pass into the trachea or the oesophagus 26 MANAGEMENT OF MEDICAL EMERGENCIES IN DENTAL PRACTICE - 60

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28. PREVENTION Rubber dam Oral packing Chair position Dental assistant Magill’s intubation forceps 28 MANAGEMENT OF MEDICAL EMERGENCIES IN DENTAL PRACTICE - 60

29. MANAGEMENT Re-establishment of airway: NON INVASIVE PROCEDURES Forceful coughing Back blows Heimlich Maneuver Chest thrust Finger sweeps INVASIVE PROCEDURES Tracheotomy Cricothyrotomy 29 MANAGEMENT OF MEDICAL EMERGENCIES IN DENTAL PRACTICE - 60

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31. HYPERVENTILATION Excessive rate and depth of respiration leading to abnormal loss of carbon dioxide from the blood primarily predisposed to anxiety. Characterised by: Rapid short strained breaths Cold Sweats Palpitations Dizziness Chest muscle fatigue Prevention includes practicing stress reduction protocols and administration of psychosedatives . 31 MANAGEMENT OF MEDICAL EMERGENCIES IN DENTAL PRACTICE - 60

32. PATHOLOGY MANAGEMENT 32 MANAGEMENT OF MEDICAL EMERGENCIES IN DENTAL PRACTICE - 60

33. ASTHMA A clinical state of hyper reactivity of the tracheobronchial tree, characterized by recurrent paroxysms of dyspnea and wheezing In diagnosed pts, not an emergency. Results from constriction of smooth muscles of the tracheobronchial tree resulting from infection, inflammation or a genetic disposition. 33 MANAGEMENT OF MEDICAL EMERGENCIES IN DENTAL PRACTICE - 60

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35. Predisposing factors-INTRINSIC & EXTRINSIC EXTRINSIC OR ALLERGIC ASTHMA The allergens may be airborne – house dust, feathers, animal dander, furniture stuffing, fungal spores, or plant pollens. Food and drugs – cow’s milk, egg, fish, chocolate, shellfish, tomatoes, penicillins , vaccines , asprin , and sulfites. Type I hypersensitivity reaction – Ig E antibodies produced in response to allergen Approximately, 50% asthmatic children become symptomatic before reaching adulthood 35 MANAGEMENT OF MEDICAL EMERGENCIES IN DENTAL PRACTICE - 60

36. Usually develops in adult age > 35 years Non allergic factors – respiratory infection, physical exertion, environmental and air pollution, and occupational stimuli. Psychological and physiologic stress can also contribute to asthmatic episodes. Acute episodes are usually more fulminant and severe than those of extrinsic asthma. Long-term prognosis also less optimistic. INTRINSIC OR IDIOSYNCRATIC OR NON-ATOPIC ASTHMA 36 MANAGEMENT OF MEDICAL EMERGENCIES IN DENTAL PRACTICE - 60

37. MANAGEMENT Summon EMS 37 MANAGEMENT OF MEDICAL EMERGENCIES IN DENTAL PRACTICE - 60

38. CARDIOVASCULAR EMERGENCIES 38 MANAGEMENT OF MEDICAL EMERGENCIES IN DENTAL PRACTICE - 60

39. ANGINA PECTORIS MYOCARDIAL INFARCTION 39 MANAGEMENT OF MEDICAL EMERGENCIES IN DENTAL PRACTICE - 60

40. ANGINA PECTORIS Definition- “A condition marked by severe pain in the chest, often also spreading to the shoulders, arms, and neck, owing to an indequate blood supply to the heart.” Types: Stable (classic or exertional) Variant ( prinzmetal , vasospastic ) Unstable (crescendo, acute coronary insufficiency) Prevention includes stress reduction protocol, reassurance & psychosedation . Webster-Merriam’s Medical Dictionary. 12 th ed. Baltimore:Williams;2011. “Angina Pectoris”; p73 40 MANAGEMENT OF MEDICAL EMERGENCIES IN DENTAL PRACTICE - 60

41. Recognize problem (chest pain – angina attack) Discontinue dental treatment Activate office emergency team P – Position, patient comfortably usually upright A → B → C – Assess and perform BLS D – definitive management HISTORY OF ANGINA PRESENT NO HISTORY OF ANGINA Administer vasodilator and O 2 Activate EMS Transmucosal nitroglycerine spray O 2 and nitroglycerine Or sublingual nitroglycerine tablet Monitor and record 0.3 – 0.6 mg for every 5 min (3 doses)   IF PAIN RESOLVES IF PAIN DOES NOT RESOLVE continue with dental procedure summon medical care Administer aspirin Continue to monitor and record vital signs 41 MANAGEMENT OF MEDICAL EMERGENCIES IN DENTAL PRACTICE - 60

42. MYOCARDIAL INFARCTION DEFINITION- “A clinical syndrome caused by deficient coronary arterial blood supply resulting in ischaemia to a region of the myocardium and causing cellular death and necrosis.” Predisposing Factors: Atherosclerosis and coronary artery disease Coronary thrombosis, occlusion and spasm Males 5 th and 6 th decades of life Undue stress Webster-Merriam’s Medical Dictionary. 12 th ed. Baltimore:Williams;2011. “Myocardial Infarction”; p197 42 MANAGEMENT OF MEDICAL EMERGENCIES IN DENTAL PRACTICE - 60

43. DENTAL CONSIDERATIONS Avoid overstressing the patient Supplemental oxygen via nasal cannula or nasal hood during the treatment – 3-5 L/min and 5 – 7 L/min Pain control during therapy – appropriate use of local anesthesia – smaller dose with maximum effect – slow administration Psychosedation – N 2 O – O 2 is preferable It is strongly recommended that elective dental care is avoided until at least 6months after MI Inferior alveolar NB and Posterior superior alveolar NB – risk of hemorrhage – should be avoided 43 MANAGEMENT OF MEDICAL EMERGENCIES IN DENTAL PRACTICE - 60

44. MANAGEMENT Protocol common for both ACS outcomes NOTE: In a patient experiencing chest pain for the very first time, summon medical assistance immediately before any self-support measures. Thereafter, continue with immediate emergency protocol as with AP. 44 MANAGEMENT OF MEDICAL EMERGENCIES IN DENTAL PRACTICE - 60

45. MANAGEMENT OF MEDICAL EMERGENCIES IN DENTAL PRACTICE - 60 45 PORTABLE AUTOMATIC EXTERNAL DEFIBRILLATOR(AED)

46. DRUG RELATED EMERGENCIES 46 MANAGEMENT OF MEDICAL EMERGENCIES IN DENTAL PRACTICE - 60

47. OVERDOSE REACTIONS In a dental practice, commonest overdosage >>LA Predisposing factors for over dosage: Pt age/body wt Route of administration Presence of vasoconstrictor Type of local anaesthetic Drug dosage formulation vital D H X 47 MANAGEMENT OF MEDICAL EMERGENCIES IN DENTAL PRACTICE - 60

48. CLINICAL MANIFESTATIONS Confusion, talkativeness, blurred speech Muscular twitching, facial tremor Headache, tinnitus Drowsiness, disorientation Elevated BP,HR,RR If uncontrolled, generalised tonic clonic seizures, generalised CNS carbopathy . 48 MANAGEMENT OF MEDICAL EMERGENCIES IN DENTAL PRACTICE - 60

49. MANAGEMENT Administer basic life support 100% oxygen, anticonvulsants Allow recovery to occur In case of continuation of symptoms, summon EMS. 49 MANAGEMENT OF MEDICAL EMERGENCIES IN DENTAL PRACTICE - 60

50. ALLERGY DEFINITION- “A hypersensitive state of skin and various mucosae acquired through exposure to a particular allergen, reexposure to which produces a heightened emergent capacity to react” Occuring via expression of IgE in response to allergen exposure 50 MANAGEMENT OF MEDICAL EMERGENCIES IN DENTAL PRACTICE - 60

51. MANAGEMENT Reassure pt. Initiate basic life support as needed. Administer antihistaminics ( diphenhydramine 50mg), epinephrine 0.123-0.3ml of 1:1000 i.m / s.c Monitor vitals regularly. Summon EMS 51 MANAGEMENT OF MEDICAL EMERGENCIES IN DENTAL PRACTICE - 60

52. EMERGENCY DRUG KIT 52 MANAGEMENT OF MEDICAL EMERGENCIES IN DENTAL PRACTICE - 60

53. FUNCTIONAL EMERGENCIES 53 MANAGEMENT OF MEDICAL EMERGENCIES IN DENTAL PRACTICE - 60

54. NEEDLE STICK INJURY Injury made with any sharp instrument, not just. Encountered more commonly by the practitioner. Stop procedure immediately. Wash skin with disinfectant. Treat with running water and encourage bleeding Dry area and cover with antiseptic dressing Recording medical history vital in case of an exposed needle situation. Seek antidotal vaccination or treatment if necessary. 54 MANAGEMENT OF MEDICAL EMERGENCIES IN DENTAL PRACTICE - 60

55. NEEDLE BREAKAGE Invariably associated with faulty techniques such as: bending the needle while administering LA inserting the needle upto the hub directing the needle against resistance May also occur if pt jerks head during administration. Most commonly with IANB. Elasticity of soft tissue produces rebound, burying the fragment within. 55 MANAGEMENT OF MEDICAL EMERGENCIES IN DENTAL PRACTICE - 60

56. MANAGEMENT Inform pt of the occurance , tell him/her to remain calm, keep mouth open and refrain from any jaw movements. Retrieve the fragment, if visible, with a haemostat . A buried fragment needs to be located ASAP using radiographs or CT scans & retrieved surgically. 56 MANAGEMENT OF MEDICAL EMERGENCIES IN DENTAL PRACTICE - 60

57. SUMMARY & CONCLUSION ALWAYS BE PREPARED Prompt recognition and efficient management of medical emergencies by a well-prepared dental team can increase the likelihood of a safe & satisfactory outcome. Basic life support training- A MUST As always, prevention is better than cure. 57 MANAGEMENT OF MEDICAL EMERGENCIES IN DENTAL PRACTICE - 60

58. REFERENCES Malamed SF. Medical Emergencies in the Dental Practice. 4 th ed. Baltimore: Elsevier; 2007 Limmer D, O’Keefe M. Emergency Care. 10 th ed. St.Louis : Macmillan Co; 2010 Malik NA. Textbook of Oral & Maxillofacial Surgery. 2 nd ed. New Delhi: Jaypee Brothers Pub; 2008 58 MANAGEMENT OF MEDICAL EMERGENCIES IN DENTAL PRACTICE - 60

59. Haas DA. Management of Medical Emergencies in the Dental Office: Conditions in Each Country, the Extent of Treatment by the Dentist. J Anaesth Prog 2006;53(2):20-24 Geller S, Malamed SF. Knowing Your Patient. J Am Dent Assoc 2010;104:3S-7S 59 MANAGEMENT OF MEDICAL EMERGENCIES IN DENTAL PRACTICE - 60

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