Medical Emergencies in Dentistry/Dental practices

Medical emergencies in dental practice refer to sudden, unexpected health-related events that can occur during dental treatment, requiring immediate attention and intervention. These emergencies may include allergic reactions, syncope (fainting), angina, asthma attacks, seizures, hypoglycemia, or cardiac arrest. Dental professionals must be trained to recognize these situations promptly and equipped to provide basic life support, manage the emergency effectively, and ensure the patient’s safety until further medical help arrives.

1. Medical emergencies in dental practice “ When you prepare for emergencies, they cease to exist” BY DR. POONAM NARANG P.G 1ST YEAR DEPT. OF PUBLIC HEALTH DENTISTRY

2. TABLE OF CONTENTS INTRODUCTION URGENCY VS EMERGENCY ABCDE APPROACH BASIC LIFE SUPPORT EMERGENCY DRUGS AND EQIPMENTS COMMON MEDICAL EMERGENCIES IN DENTAL PRACTICES CONCLUSION REFERENCES

3. INTRODUCTION A Medical Emergency is defined as a serious and unexpected situation involving illness or injury and requiring immediate action. [1] Every dentist should have a basic knowledge to recognise, assess & manage a potentially life threatening situation. Life threatening emergencies can and do occur in the practice of dentistry. These emergencies range from minor such as common faint and hyperventilation to life threatening such as cardiac arrest. Ramanayake RPJC, Ranasingha S, Lakmini S. Management of emergencies in general practice: role of general practitioners. J Family Med Prim Care [Internet]. 2014;3(4):305–8.

4. ASA 1: A normal healthy patient. ASA 2: A patient with mild systemic disease. ASA 3: A patient with a severe systemic disease that is not life-threatening. ASA 4 : A patient with a severe systemic disease that is a constant threat to life. ASA 5: A moribund patient who is not expected to survive without the operation. The patient is not expected to survive beyond the next 24 hours without surgery. ASA 6: A brain-dead patient whose organs are being removed with the intention of transplanting them into another patient. The higher the ASA class, the more at-risk the patient is both from a surgical and anaesthetic perspective. Abbreviations used: ASA: American Society of Anaesthesiologists. RISK ASSESMENT OF PATIENT [2] Source- Doyle DJ, Hendrix JM, Garmon EH. American Society of Anesthesiologists classification. StatPearls Publishing; 2023. "How healthy is the patient"

5. Urgencies Urgency : A problem that requires prompt response; it is not immediately life threatening but could become so if not resolved promptly. Emergency : A problem that is immediately life threatening and requires immediate action. Syncope Hypoglycaemia Seizure Asthmatic attack Hyperventilation Angina Mild allergic reaction Cardiac arrest Anaphylaxis Obstructed airway VS Emergencies

6. Laura M. Cascella, MA. Preparing for Medical Emergencies in Healthcare Practices [3]

7. 1. PREVENTION Medical questionnaire Doctor patient encounter Physical examination 2. PREPARATION Staff training Emergency equipments Experienced emergency medical services (EMS) 3. ACTION BLS

8. The immediate management of any emergency should follow an appropriate, defined protocol or action plan. If the patient is responsive (or unresponsive), if they are breathing normally and you can feel their pulse, begin your management using the A B C D E mnemonic as follows: A is for Airway – open the airway by tilting the head and lifting the chin if necessary. Remove any dental instrumentation and ensure the airway is protected. B is for Breathing – check for adequate ventilation, and consider giving oxygen if necessary. C is for Circulation – look for signs of bleeding and shock. D is for Disability – carry out an AVPU assessment – that is Alert, responding to Voice, responding to Pain, Unconscious. E is for Expose – expose the patient’s body enough to carry out a medical assessment, but keep them warm and maintain their dignity. Immediate management of potential emergencies

9. BASIC LIFE SUPPORT [4] “Single important step in preparation for medical emergencies” In all emergency situations without exception, initial management will always entail the application as needed of the steps of basic life support. Drug therapy is always relegated to a secondary role. Source- AHA Guidelines

10. ADVANCED CARDIAC LIFE SUPPORT (ACLS) OR ADVANCED CARDIOVASCULAR LIFE SUPPORT (ACLS) REFERS TO A SET OF CLINICAL INTERVENTIONS FOR THE URGENT TREATMENT OF CARDIAC ARREST, STROKE AND OTHER LIFE- THREATENING CARDIOVASCULAR EMERGENCIES, AS WELL AS THE KNOWLEDGE AND SKILLS TO DEPLOY THOSE INTERVENTIONS. ACLS is a series of evidence based responses simple enough to be committed to memory and recall under moments of stress. AMERICAN HEART ASSOCIATION (AHA) protocols are considered to be the GOLD standard ACLS protocol ADVANCED CARDIOVASCULAR LIFE SUPPORT (ACLS) Source- AHA

11. INDICATION: Road Traffic Accident Drowning Electric Shock Airway Obstruction Cardiac Arrest

12. FLOW CHART OF ACLS UNRESPONSIVE CALL FOR HELP START BLS ATTACH MONITER & DEFIBRRILATOR WHEN AVALIABLE CHECK RHYTHM 1 ST SHOCK (150-200 BIAPHASIC) CPR 30:2 (2min)

13. 2 ND SHOCK(150-360) CPR 30:2 (2min) ADRENALINE 1 MG IV EVERY 3-5 MIN 3 RD SHOCK CPR 30:2 (2min) IF PULSE PRESENT: START POST RESUSCITATION CARE OR STILL NO PULSE SEEN AND ASYSTOLE SEEN: CONTINUE THE CPR AND SWTICH ON TO NON SHOCKABLE TREATMENT.

14. ANTIBIOTIC PROPHYLAXIS BEFORE SURGERY

15. EMERGENCY DRUGS AND EQUIPMENT DRUGS ROUTES OF ADMINISTRATION Oxygen Inhalation Glyceryl trinitrate spray (400 μg per actuation) Sublingual Dispersible aspirin (300 mg) Oral (chewed) Adrenaline injection (1:1000, 1 mg/mL) Intramuscular Salbutamol aerosol inhaler (100 μg per actuation) Inhalation Glucagon injection (1 mg) Intramuscular/subcutaneous Oral glucose solution/gel (GlucoGel ) Oral Midazolam 10 mg or 5 mg/mL (buccal or intra-nasal) Infiltration/inhalation

16. Nitroglycerin Midozolam Aromatic ammonia(spirit) Glucogel

17. EQUIPMENT • Portable oxygen cylinder with pressure reduction valve and flowmeter • Portable suction with appropriate suction catheters and tubing • Ambu bag with face masks for adults and children • Single use sterile syringes and needles • Stethoscope •Sphygmomanometer (Electronic, Aneroid, Mercury) • Spacing device for inhaled bronchodilators • Automated external defibrillators (AED) • Nebulisers • Automated blood glucose measurement device • Oropharyngeal airways (sizes 1,2,3, and 4) • Oxygen face mask with tubing

18. O2 cylinder

19. Various sizes of oro-pharyngeal airway.

20. Bronchodilator Spacer device

21. Automated external defibrillator (AED)

22. COMMON MEDICAL EMERGENCIES ENCOUNTERED IN DENTAL PRACTICE

23. ALTERED CONSCIOUSNESS Diabetes mellitus: hyperglycemia and hypoglycemia Thyroid gland dysfunction (hyperthyroidism and hypothyroidism) Cerebrovascular accident CHEST PAIN Angina pectoris Acute myocardial infarction SUDDEN CARDIAC ARREST Common medical emergencies in the dental office UNCONSCIOUSNESS Vaso depressor syncope Orthostatic hypotension Acute adrenal insufficiency RESPIRATORY DISTRESS Airway obstruction Hyperventilation Asthma (bronchospasm) Heart failure and acute pulmonary oedema SEIZURES DRUG-RELATED EMERGENCIES Drug overdose reactions Allergy

24. "Simple faint" is the most common medical emergency in dental practice, causing loss of consciousness due to inadequate cerebral perfusion. It's a reflex mediated by autonomic nerves, resulting in vasodilation and bradycardia. Triggers include pain, emotional stress, posture changes, or hypoxia. Fainting-prone patients should be treated supine. A similar clinical picture may be seen in ‘carotid sinus syndrome’ . Mild pressure on the neck in such patients (usually, the elderly) leads to a vagal reaction producing syncope. This situation may progress to bradycardia or even cardiac arrest. 1. Vasovagal syncope (simple faint)

25. Fainting – signs and symptoms Patient feels faint/light headed/dizzy Pallor sweating Pulse rate slows Low blood pressure Nausea and/or vomiting Loss of consciousness Fainting – treatment Lay the patient flat and raise the legs – recovery will normally be rapid. A patent airway must be maintained. If recovery is delayed, oxygen should be administered and other causes of loss of consciousness be considered.

26. The unconscious victim should be positioned with the thorax and brain at the same level and the feet elevated slightly (about 10 or 15 degrees) . The position aids in the return of venous blood to the heart. Pregnant patient placed on right side if unconscious.

27. 2. ACUTE ADRENAL INSUFFICIENCY PREDISPOSING FACTORS Addison’s disease Secondary insufficiency Stress Acute adrenal insufficiency is a true medical emergency in which the victim is in immediate danger because of glucocorticoid (cortisol) deficit. Peripheral vascular collapse (shock) and ventricular asystole (cardiac arrest) are the usual cause of death.

28. CLINICAL MANIFESTATIONS Weakness and fatigue Anorexia Weight loss Hyperpigmentation Hypotension Hypoglycemia Nausea, vomiting Syncope Lethargy Confusion(marked most notably) Psychosis

29. DENTAL THERAPY CONSIDERATIONS Glucocorticosteroid coverage : With milder stress like single dental extraction, use double daily dose. In moderate stress like surgery under local anaesthesia, several dental extractions, use Hydrocortisone 100mg or prednisolone 20 mg or Dexamethasone 4 mg daily. Severe stress like in severe trauma use Hydrocortisone 200mg, or prednisolone 40 mg or Dexamethasone 8 mg daily.

30. Algorithm for the management of an acute adrenal crisis: Signs and symptoms: Confusion, sweating, vomiting, diarrhoea, hypotension, loss of consciousness, convulsions and ultimately circulatory collapse. Give high flow O 2 Place patient supine Alert emergency services 108 Administer hydrocortisone 200mg IV or IM

31. 3. DIABETES MELLITUS Stress increases body resistance to insulin and so patients may develop hyperglycaemia during treatment. Type 2 Diabetics are less prone to complications that develop during treatment as compared to type 1 which are more prone to ketosis. Diabetes mellitus (DM) is a disease of glucose, fat, and protein metabolism resulting from impaired insulin secretion, varying degrees of insulin resistance, or both.

32. DENTAL THERAPY CONSIDERATIONS Advise the patients to take usual insulin dose and to eat normal breakfast before treatment. Schedule dental appointments early in the day to minimise the episodes of hypoglycaemia. Dental appointment scheduling should avoid appointments that will overlap with or prevent scheduled meals.

33. For prolonged procedures, especially if they encroach on mealtime, intra-operative blood glucose evaluation is advisable. Use of LA without epinephrine Use of shorter acting LAs eg Mepivacaine plain versus longer acting eg Bupivacaine with epinephrine will minimise postoperative eating impairment. DENTAL THERAPY CONSIDERATIONS

34. Hyperglycemia Diagnostic clues: Florid face, dry, warm skin Kussmaul’s respiration Fruity odour Rapid, weak pulse normal to low BP Rapid HR

35. Management of hyperglycaemic patient (unconscious patient) Terminate dental procedure Position the patient BLS Summon medical assistance IV infusion (5% dextrose and water) administer oxygen If diagnosis in doubt, administer glucose paste Transport to hospital

36. Diagnostic clues: Sweating, tachycardia (sympathetic overactivity) Weakness, dizziness Pale, moist skin ,and cold skin (in contrast to hyperglycaemia) Shallow respiration Headache Altered consciousness Hypoglycaemia

37. Terminate dental procedure Position the patient BLS Administer 15 gms of oral carbohydrate No improvement – administer parentral carbohydrate or glucagon if available or intravenous dextrose. Observe patient atleast for 1 hour before discharging Management (conscious patient)

38. Terminate dental procedure Position patient in supine patient BLS Summon medical assistance Definitive management (50%dextrose iv, 1mg glucagon IM, transmucosal sugar). If none of the two is available, 0.5mg dose of 1:1000 conc epinephrine SC or IM every 15 minutes Hypoglycemia (unconscious patient)

39. The well-controlled diabetic is probably at no greater risk of postoperative infection than is the non-diabetic. Therefore, routine dentoalveolar surgical procedures in well- controlled diabetics do not require prophylactic antibiotics. However, when surgery is necessary in the poorly controlled diabetic, prophylactic antibiotics should be considered.

40. Tongue Foreign bodies Most common cause 4. AIRWAY OBSTRUCTION

41. PREVENTIVE MEASURES Rubber dam Oral packing Chair position Suction Magill intubation forceps

42. CAUSES OF PARTIAL AIRWAY OBSTRUCTION SOUND HEARD Snoring MANAGEMENT head tilt CAUSE Hypo-pharyngeal obstruction by tongue Gurgling Foreign body Suction Wheezing Airway/Bronchial obstruction Administer bronchodialator

43. PHASE COMPLETE UPPER AIRWAY OBSTRUCTION First phase (1 to 3 min) Second phase (2 to 5 min) Third phase (4 to 5 min) SIGNS AND SYMPTOMS universal choking sign struggling, paradoxical respiration loss of consciousness, decreased respiration, BP and pulse coma, absent vital signs, dilated pupils

44. Basic airway manoeuvres Head tilt–chin lift- The patient’s neck tissues are extended using the head tilt–chin lift technique. In 80% of instances in which the tongue is the cause of the airway obstruction, this procedure effectively opens the airway. 55 Jaw-thrust manoeuvre- The rescuer places his or her fingers behind the posterior border of the ramus of the victim’s mandible displacing the mandible anteriorly while tilting the victim’s head backward and opening the mouth.

45. Back blows (back slaps)- Stand to the side and just behind a choking adult. For a child, kneel down behind. Place your arm across the person's chest to support the person's body. Bend the person over at the waist to face the ground. Strike five separate times between the person's shoulder blades with the heel of your hand. A number of non invasive procedures are available for use in acute airway obstruction. The techniques are as follows:

46. Abdominal thrust-(HEMILICH MANEOVRE) Stand behind the person and put your arms around their belly (abdomen). Make a fist with one hand and clasp your other hand tightly around it. Place the thumb side of your fist just below their ribcage and about two inches above their belly button (navel). Sharply and quickly thrust your hands inward and upward five times. Repeat this process until you free (dislodge) the object stuck in their windpipe, or the person becomes unconscious. If the person becomes unconscious, start CPR.

47. Chest thrust- If the victim is pregnant or obese, chest thrusts should be used in place of abdominal thrusts. From behind the person wrap your arms around their chest just under the armpits. Make a fist with one hand and place it thumb side inward in the middle of the victims chest. Grasp fist with other hand and forcefully press inward in centre of chest. If the person becomes unconscious, start CPR.

48. The rescuer uses the heel of one hand to deliver up to five back slaps forcefully between the shoulder blades of an infant. Technique for an infant with an obstructed airway. A, The infant should be supported by the rescuer’s forearm with the head lower than the rest of the body for performance of back blows. B, The infant is turned over, supported by the rescuer’s arms. Using two fingers, the rescuer applies chest thrusts.

49. DENTAL CONSIDERATIONS Do not permit patient to sit up Place chair in more reclined position (Trendelenberg position) and try to remove object with Magill intubation forceps. Left lateral position with head down. Radiographs . Magill intubation forceps. Trendelenberg position

50. If objects enter into the trachea : Place the patient in left lateral position Encourage patient to cough Object is retrieved Initiate medical consultation prior to discharge not retrieved, consult with radiologist appropriate radiograph perform endoscopy

51. RECOMMENDED SEQUENCE FOR REMOVING AIRWAY OBSTRUCTION FOR ADULT CONSCIOUS VICTIM WITH OBSTRUCTED AIRWAY Identify complete airway obstruction Apply Heimlich maneuver until foreign body is expelled or victim become unconscious have medical evaluation of patient before discharging FOR ADULT UNCONSCIOUS VICTIM WITH OBSTRUCTED AIRWAY Assess responsiveness Position patient in supine with feet elevated Open airway (head tilt – chin lift) Assess breathing (look, listen and feel) Attempt to ventilate. If unsuccessful Reposition head and reattempt to ventilate Perform Heimlich manoeuvre Perform foreign body check: finger sweep

52. It is defined as ventilation in excess of that required to maintain normal blood PaO 2 and PaCO 2 . Produced by increase in either the frequency or depth of respiration or a combination of the two. 5. HYPERVENTILATION

53. Anxiety (Most common) Metabolic conditions Pain Metabolic acidosis Drug intoxication PREDISPOSING FACTORS age 15-40 years of age no sex difference anxiety most common

54. Neurologic – dizziness, lightheadedness, numbness and tingling of extremities Psychologic – tension, anxiety, nightmares CV – palpitations, tachycardia, precordial pain Musculoskeletal – muscle pain and cramps, stiffness, tetany GI – epigastric pain Respiratory – shortness of breath, chest pain CLINICAL MANIFESTATIONS

55. Terminate procedure Position patient (upright) Calm patient Correct respiratory alkalosis Rebreathing bag (exhaled air) Initial drug management - Benzodiazepines Management

56. 6. ASTHMA Disease characterised by an increased responsiveness of trachea and bronchi to various stimuli and manifested by widespread narrowing of airways that changes in severity either spontaneously or as a result of therapy. American Thoracic society Can be: 1.Extrinsic Asthma 2.Intrinsic Asthma 3.Status Asthmaticus

57. Feeling of chest congestion Cough with or without sputum production Wheezing Dyspnea Tachypnea BP – baseline to elevated Heart Rate increased Diaphoresis/ sweating Confusion Cyanosis Supraclavicular and intercostal retraction Nasal flaring SIGNS AND SYMPTOMS OF ACUTE ASTHMA

58. Proper stress reduction protocol. No need to use of any conscious sedation technique except for drugs like barbiturates and narcotics especially mepiridine which can precipitate bronchospasm in these patients. Inhalation anaesthetics like ether that irritate respiratory mucosa are capable of inducing bronchospasm in these patients. However N2O is safe for these patients. Drugs like NSAIDS and penicillin must be avoided. Sulphating agents such as Sodium metabisulphite used as antioxidant for epinephrine in LA can provoke bronchospasm and should be avoided. DENTAL THERAPY CONSIDERATIONS

59. Discharge patient MANAGEMENT OF ACUTE ASTHAMATIC ATTACK Terminate dental procedure Position the patient in sitting position with arms thrown forwards Remove dental materials from patient’s mouth Calm the patient Basic life support Administer bronchodilator via inhalation* Episode terminates Episode continues Subsequent dental care administer oxygen Administer parenteral medications hospitalise patients

60. The most serious and life threatening allergic reaction is anaphylactic shock. The body's vital functions of breathing and circulation are impaired and oxygen cannot reach organs like the brain. Anaphylactic shock manifests itself with markedly lowered blood pressure, dilated blood vessels, swelling and hives. If the anaphylactic reaction is mainly affecting the respiratory system, it may result in bronchospasm or laryngeal oedema. The treatment for bronchospasm is the same as for an asthma attack. 7. Anaphylactic Shock

61. Mild Allergic Reaction Moderate Allergic Reaction Severe Allergic Reaction Localized redness Localized pruritus Localized urticaria Edema Conjunctivitis Pale or flushed skin Rhinitis Systemic redness Systemic pruritus Systemic urticaria Edema Rhinitis Bronchospasm/dyspnea Abdominal pain Cramping Diarrhea Systemic redness Systemic pruritus Systemic urticaria Severe hypotension Dyspnea Angioedema of the eyes, lips, or larynx Signs and Symptoms of Allergic Reactions

62. Treatment algorithm

63. 8. ANGINA PECTORIS Angina is a latin word meaning a spasmodic, cramp like , choking feeling, or suffocating pain. A condition marked by severe pain in the chest, often spreading to the shoulders, arms and neck owing to an inadequate blood supply to the heart. In the dental office may be precipitated by the anxiety while attending the dental surgery. If the patient may have had attacks of angina in the past he/she will recognise the symptoms itself

64. CAUSES Coronary artery atherosclerosis Coronary artery spasm Multiple other cardiac and pulmonary etiologies

65. Poorly localized pain - Usually retrosternal but may occur anywhere from lower jaw to umbilicus Moderate intensity pain - described as squeezing, oppressive, burning or heavy Brief duration – 2-10 minutes CLINICAL CHARACTERISTICS Emotional distress Physical exertion Heavy meals Cold Walking up stairs or hills Precipitated by : Recumbency Exacerbated by :

66. EXCLUDED IF: Pain localised with one finger Lasts less than 30 seconds or longer than 30 minutes Pain described as sticking, jabbing, throbbing or constantly severe

67. DIAGNOSTIC APPROACH Nitroglycerin Normally relieves pain in 3 minutes or less Failure to relieve pain after 10 minutes evidence against angina Failure to relieve pain indicates either unstable angina or myocardial infarction DENTAL TREATMENT Early morning appointments Short appointments Stress reduction protocols Adequate pain control

68. Position patient to comfort Oxygen 2-3 L per NC or face mask Nitroglycerin 0.4 mg SL spray or 0.15–0.9 mg SL tablet Repeat for 5 minutes If pain is not relieved with 3 doses of nitroglycerin, give one aspirin 325 mg and call EMS. Ensure that vital signs, drug administration, and patient responses are properly monitored and recorded. Facilitate next steps in medical care (transport to hospital if needed); reassure patient TREATMENT

69. It is a clinical syndrome resulting from deficient coronary artery blood supply to a region of myocardium that results in cellular death and necrosis. No elective dental care for atleast 6 month postoperative. 9. Myocardial Infarction

70. Pain more intense and longer in duration than angina pectoris Pain described as retrosternal, crushing, pressure, constriction, burning Pain may occur in same distribution as angina pectoris Not relieved by SL nitroglycerin or cessation of activity Myocardial Infarction

71. SYMPTOMS Pain Nausea/Indigestion Weakness/Fatigue Dizziness Palpitations Sense of impending doom Lightheadedness SIGNS Restlessness Acute distress Vomiting Cardiac arrhythmia Pallor Cyanosis Dyspnea Wheezing MI SIGNS AND SYMPTOMS

72. Recognition Airway Breathing Circulation Activate EMS BLS Oxygen - 4-5 L by NC or face mask Administer: Aspirin 160 to 325mg oral & manage pain by giving parenteral opioids, N 2 O-O 2 Monitor and record vital signs Stabilize and transfer to hospital emergency department Management of Acute MI

73. 10. HYPOTHYROIDISM A condition in which the thyroid gland doesn't produce enough thyroid hormone. Myxedema coma is defined as severe hypothyroidism leading to decreased mental status, hypothermia, and other symptoms related to slowing of function in multiple organs. It is a medical emergency with a high mortality rate. Diagnostic clues : Cold intolerance Weakness Fatigue Dry, cold, yellow skin Thick tongue

74. Terminate dental procedure Supine position A,B,C should be maintained Establish iv access, if possible (5%dextrose) Administer oxygen IV doses of thyroid hormone MANAGEMENT

75. 11 . HYPERTHYROIDSM DIAGNOSTIC CLUES : Sweating Heat intolerance Tachycardia Warm, thin, moist skin Exophthalmos Tremor It is the overproduction of thyroxine hormone by thyroid gland.

76. MANAGEMENT Similar to that of hypothyroidism except that instead of thyroid hormone, antithyroid drugs are required in this case (eg propylthiouracil) and Glucocorticoids to prevent the occurance of acute adrenal insufficiency.

77. Hyperthyroidism :- stress in these patients can precipitate thyroid storm. Use of atropine, a vagolytic agent(inhibits vagus) should be avoided. Epinephrine should be used with caution (in minimal possible dose) Hypothyroidism : - caution in using CNS depressant drugs like sedative – hypnotics, opioid analgesics, antianxiety drugs, CNS depressants. DENTAL THERAPY CONSIDERATIONS

78. It is a paroxysmal disorder of cerebral function characterized by an attack, involving changes in the state of consciousness motor activity or sensory phenomena. Usually sudden in onset and of brief duration. EPILEPSY: “ a chronic disorder in which nerve cell activity in the brain disturbed, causing seizures” 12 . Seizures ( convulsions) STATUS EPILEPTICUS condition in which seizures are so prlonged & repeated that recovery does not occur between attacks. TONIC A sustained muscular contraction : patient appears rigid or stiff during this phase. CLONIC Intermittent muscular contractions and relaxations- actual convulsive portion of a seizure.

79. Common symptoms of seizures

80. Prevention Minimal or moderate sedation Inhalation sedation with nitrous oxide and oxygen is a highly recommended route of sedation for the apprehensive epileptic patient because it allows the administrator a great degree of control over its actions.

81. Management Terminate the dental procedure Position the patient- patient is placed on the floor in the supine position Ensure adequate ventilation – loosen the clothes Prevent injury 1. restrain the victims arms and legs from gross movements 2. Placement of any objects into patient’s mouth is not indicated during the seizure 3. Soft items such as guaze pads, towels, are placed in mouth to prevent injury to intraoral soft tissues. Basic life support, as indicated. Call the medical assistance. Midazolam given via the buccal or intra-nasal route (10 mg for adults). The buccal preparation is marketed as ‘Epistatus’ (10 mg/mL) Monitor vital signs. Reassure the patient and recovery – normal cerebral functioning after 2 hours.

82. It is a phenomenon marked by circulatory deficiency which is either cardiac or vasomotor in origin exhibiting marked hypotension. SHOCK Signs and symptoms: Unconsiousness Mucous membrane is pale Lips, nails & finger tips and lobules of the ear are grayish blue Face is expression less with sunken eyes Pupils are dilated but react feebly to light Pulse is weak and thready Shallow and irregular respiration Temperature is subnormal

83. Recognition Airway Breathing Circulation Activate EMS BLS Administer 100% oxygen Control blood loss Restore body fluids Monitor and record vital signs Hydrocortisone sodium hemisuccinate 100-500mg in 5 ml of water IV Inj Mephentermine Inj Atropine and narcotic analgesics Management of Shock

84. The Mobile Dental Clinic is used primarily when oral health care is to be delivered to small pockets of patients that are scattered. Target Populations Low Income Individuals. Rural populations. Very young children. Persons in residential care facilities. Bedridden Individuals. Persons with variety of health care needs. Migrants and seasonal workers. Homeless or temporarily displaced over a specific geographical area. Essential Emergency Drugs and Equipment for Mobile Dental Vans

85. American Red Cross & Centers for Disease Control and Prevention (CDC) Emergency Action Plan (EAP) Communication Medical Supplies Emergency Equipment Access to Medical Care Staff Training Participant Information Supervision and Monitoring Documentation and Reporting The precautions outlined for managing medical emergencies at camp sites:

86. Emergency Drugs : Epinephrine auto-injectors Nitroglycerin Diphenhydramine (Benadryl) Aspirin Salbumatol Hydrocortisone Morphine Diazepam/midazolam Glucose gel or tablets Emergency Equipment : Oxygen delivery system Portable suction unit Blood pressure monitor Glucometer Stethoscope Automated external defibrillator (AED) Oral airways Intravenous (IV) access kit Emergency drugs storage box Emergency drugs and equipments that should be available in mobile dental clinic

87. CONCLUSION Medical emergencies can happen anywhere. Being prepared for medical emergencies in dentistry is crucial. Dental teams must prioritise ongoing training, establish clear protocols, and maintain updated equipment to ensure swift and effective responses. By prioritising patient safety and proactive preparedness, dental professionals can uphold their commitment to delivering high-quality care in any situation.

88. References Ramanayake RPJC, Ranasingha S, Lakmini S. Management of emergencies in general practice: role of general practitioners. J Family Med Prim Care; 2014;3(4):305–8. Doyle DJ, Hendrix JM, Garmon EH. American Society of Anesthesiologists classification. StatPearls Publishing; 2023. Laura M. Cascella, MA. Preparing for Medical Emergencies in Healthcare Practices | MedPro Group [Internet]. [cited 2024 Apr 25]. Available from: https://www.medpro.com/medical-emergencies-preparation Algorithms | American Heart Association CPR & First Aid. Available from: https://cpr.heart.org/en/resuscitation-science/cpr-and-ecc-guidelines/algorithms Grimes EB. Medical emergencies: essentials for the dental professional. Second edition. Boston: Pearson; 2014. Jevon P. Basic guide to medical emergencies in the dental practice. Nashville, TN: John Wiley & Sons; 2014. Malamed SF. Medical emergencies in the dental office, 7th ed. New Delhi, India: Elsevier; 2015. Greenwood M, Corbett I. Dental Emergencies. Greenwood M, Corbett I, editors. Hoboken, NJ: Wiley-Blackwell; 2012. Zingade J, Kumar G, Gujjar PK. Medical Emergencies in Dentistry: A Review. J Health Sci Res 2021;12(1):11–16.

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