Management of medical emergencies

2. Synopsis
 Introduction
 Types of emergencies
 Preparation
 Emergency drugs
 Prevention and Management
 Conclusion

3. Introduction
 A serious and unexpected situation requiring an immediate
action.
 It is an unforeseen combination of circumstances or the
resulting state that calls for an immediate action.

4. Types of emergencies
 UNCONSIOUSNESS
I. Vasodepressor Syncope
II. Acute Adrenal Insufficiency
III. Postural/Orthostatic Hypotension
IV. Hypoglycemia
 SEIZURES
 RESPIRATORY EMERGENCIES
I. Airway obstruction
II. Asthma
III. Hyper ventilation

5.  CARDIOVASCULAR EMERGENCIES
I. Angina pectoris
II. Myocardial infarction
III. Cardiac arrest
 DRUG-RELATED EMERGENCIES
I. Overdose reactions
II. Allergy
 NEEDLE STICK INJURY
Types of emergencies

7. Prevention
Goals:
 Comprehensive medical history
 Physical examination and Prompt recognition of symptoms of an
emergency
 Basic life support
 Affiliation to definitive medical care
 Vigilant observation

8. COMPREHENSIVE MEDICAL HISTORY
 Thorough questionnaire
 Past medical history
 Familial disease history
 Psychological/ social status
 Diet

9. ASA PHYSICAL STATUS CLASSIFICATION
(1962)
 ASA I: Healthy patient with no systemic disease.
 ASA II: Patient with mild systemic disease with no limits on activity.
 ASA III: Patient with severe systemic disease that limits activity. But it is not
incapacitating.
 ASA IV: Patient with incapacitating systemic disease that is constant threat to life.
 ASA V: A Moribund patient not expected to survive more than 24 hours .
 ASA 6 : Declared brain dead patient whose organ may be removed for donor purpose.
 ASA E: Emergency of any kind.

10. Preparation
 BASIC LIFE SUPPORT
 Primary response to all emergencies.
 CAB-D (Circulation > Airway > Breathing, > Defibrillate)

11. Self initiating bag valve mask Aspirator tip.
Nonelectrical suction systemPocket Mask
Posititve pressure demand
valve

14. Emergency drug
modules
 Module One: Critical(Essential)
Emergency Drugs and Equipment
 Module two—secondary
(noncritical) drugs and equipment
 Module three—advanced cardiac
life support: essential drugs
 Module four—antidotal drugs
Emergency colour code

15. EMERGENCY DRUGS
Module One: Critical(Essential) Emergency Drugs and Equipment Module two—secondary (noncritical) drugs and equipment

16. EMERGENCY DRUGS
Module four—antidotal drugsModule three—advanced cardiac life support: essential drugs

17. Healthfirst SM-Z.
CLAM: Compact Layout Auto-Injectable
Medications.
Healthfirst SM-7.Banyan Stat Kit 1000HD.

18. UNCONSCIOUSNESS

19. Syncope
 Syncope is an abrupt transient loss of consciousness associated with inability to maintain
postural tone. The episode is usually due to hypoperfusion to the cerebral cortex and the
cerebral reticular activating system.

21. Phases of Synope
Pre-syncope
• Feeling of warmness
over face and neck
• Paleness
• Sweating.
• Feels cold.
• Abdominal discomfort.
• Dizziness.
• Mydriasis (Pupillary
dilatation.)
• Yawning.
• Increased heart rate.
• Steady or slight decrease
in blood pressure
Syncope
• Patient loses
consciousness.
• Generalized muscle
relaxation.
• Bradycardia (Weak
thready pulse.)
• Seizure (Twitching of
hands, legs, and face.)
• Eyes open (Out and up
gaze.)
• Airway obstruction
Post-syncope
• Variable period on
mental confusion.
• Heart rate increases
(Strong rate and
rhythm.)
• Blood pressure back to
normal levels.

22. (10 – 15 degrees).

23. Postural or orthostatic hypotension
 Postural or orthostatic hypotension is a disorder of autonomic
nervous system in which syncope occurs when patient
assumes an upright position.
 Only BP get reduced.

24. Etiology
 Administration of drugs e.g. Antihypertensives, sedatives and narcotics histamine
blockers, levo dopa
 Prolonged period of recumbency or convalescence
 Late stage pregnancy
 Advanced age
 Venous defects in legs (e.g. varicose veins)
 Addisson’s disease
 Physical exhaustion and starvation
 Chronic postural hypotension (Shy – Drager syndrome)

26. Clinical features
 Reduced blood pressure
 Loss of consciousness
 Palpitation
 General weakness

28. Acute adrenal insufficiency
 Potentially life - threatening situation that may result in the loss of
consciousness due to adrenal insufficiency secondary to exogenous
cortico steroid administration
PREDISPOSING FACTORS:
 Lack of glucocorticosteroid hormones
 Primary adrenal insufficiency (Addison’s disease)
 Temporary insufficiency resulting from cortical suppression through
prolonged exogenous glucocorticosteroid administration (secondary
insufficiency).
 Bilateral adrenalectomy
 Injury to the both adrenal glands (trauma, infection, thrombosis, or
tumor)

29. Clinical features
Adrenocorticol suppression should be considered if the patient had a glucocorticoid therapy :
 In a dose of 20 mg or more of cortisone or its equivalent
 Via oral or parenteral route for a continuous period of two weeks or longer
 Within 2 years of dental therapy

32. Hypoglycemia
 Hypoglycemia is a common emergency condition in which low serum (or
plasma)glucose levels due to overdosage of insulin, hypoglycemic drugs etc

33. Dental consideration
 Appointments should be of short duration and early in morning
 Prior Antibiotic coverage to prevent infection
 Procedures can be carried out immediately after a meal.
 Glucose drink should be available in clinic while treating diabetic patient

34. Management
 Glucose and sugar-containing beverages administered orally to
 Conscious patients for rapid effect.
 Alternatively, milk candy bars, fruit, cheese, etc may be adequate in
mild cases.
 IV dextrose is indicated for severe hypoglycemia, in patients with
 Altered consciousness and during any restriction of oral intake.
 20-25 ml of 50% dextrose should be given immediately.
 Glucagon, 1mg IM. (Or SC.)

35. Seizures
 “A paroxysmal disorder of cerebral function characterized by a short attack involving changes
in the state of consciousness, motor activity, or sensory phenomena”
 EPILEPSY: “A chronic disorder in which nerve cell activity in the brain is disturbed, causing
seizures

37. Prevention
 If a patient is known epileptic, make sure he/she has taken their regular dose of anti-
convulsant on the day of treatment.
 Instruct him/her to alert you as the aura of the impending seizure manifests itself.
 Keep life support equipments ready, in case of an emergency status epilepticus.

38. Management
 Self limiting emergency
 Position: supine with patient placed on flat surfaces.
 Remove dangerous objects from the mouth and around the
patient.(ex. sharp instruments, needles, etc.)
 Loosen any tight clothing.
 Avoid restraining the patient.
I. Diazepam – 10 mg IV, (2mg/min) repeat every 10 minutes.
II. Phenobarbitone – 100-200 mg/min, i.v.
III. Carbamazepine
IV. Phenytoin

39. RESPIRATORY EMERGENCIES

40. Hyperventilation
 Excessive rate and depth of respiration leading to abnormal loss of
 carbon dioxide from the blood primarily predisposed to stress and
anxiety.
Characterized by:
 Rapid short strained breaths
 Cold sweats
 Palpitations
 Dizziness
 Chest muscle fatigue

42. Prevention
 Exhaled air is inhaled-in again using a paper bag.
 Done in order to “rebreathe” your exhaled CO2 to bring the body back to a normal state.
 Reduce patient’s stress and anxiousness.
 The operator should stay calm and also make the patient be relaxed.
MANAGEMENT
 Administration of Benzodiazepenes:
 Diazepam (2-5 mg IM./IV. every 3-4 hourly)
 Lorazepam (2-3 mg oral per day, BD/TD)
 Triazolam (0.25 – 0.5 mg)
 Alprazolam (0.25 – 0.5 mg oral TD)

43. Bronchial asthma
 “A chronic inflammatory disorder that is characterized by reversible
obstruction of the airways
Predisposing factors
 Extrinsic or allergic asthma
 Airborne allergens – house dust, feathers, animal dander, furniture
stuffing, fungal spores, or plant pollens.
 Food and drugs – shellfish, penicillins, vaccines , asprin, and sulfites.
 Type 1 hypersensitivity reaction – Ig e antibodies produced in response
to allergen

44.  Intrinsic or idiosyncratic or non-atopic asthma
 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
CLINICAL MANIFESTATIONS:
 Feeling of chest congestion
 Cough, with or without sputum production
 Wheezing
 Dyspnea
 Increased anxiety and apprehension
 Tachypnea (>20 - >40 in severe cases)
 Rise in B.P
 Increase in heart rate (>120 bpm in severe cases)

45. Management

46. Airway Obstruction
 During surgical procedures ,Aspiration of foreign body into air way would cause severe airway obstruction
 Occurs more common in patient positioned in a supine or semi supine position with absence of gag reflex
CLINICAL FEATURES:
 Coughing,
 Inability to speak, breathe
 Gurgling,
 Gagging to choking
 Gasping with panic.
 Absent or altered voice sounds
 Aspired object may pass into the trachea or the oesophagus

48. Non invasive procedures
Forceful coughing Chest Thrust Abdominal thrust
Finger sweeping
Back blowMagills forceps

49. Invasive procedures - Cricothryrotomy

50. CARDIOVASCULAR EMERGENCIES

51. Angina pectoris
 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
 Variant
 Unstable
PRECIPITATING FACTORS:
 Sternuvous exercise
 Hot, humid environment
 Cold whether
 Heavy meals
 Emotional stress
 Cigarette smoking
 Smog
 High altitudes

53. Management
 Medical management includes: Nitrates ,Betablockers, Calcium channel
blockers,Psychological stress management and Reassurance

54. Myocardial Infarction
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
 5th and 6th decades of life
 Stress

55. Dental considerations
 It is strongly recommended that elective dental care is avoided until at least 6months
after MI
 Avoid overstressing the patient
 Supplemental oxygen via nasal cannula or nasal hood during the treatment – 3-5L/min
and 5 – 7 L/min
 Pain control during therapy – appropriate use of local anesthesia – smaller dose with
maximum effect – slow administration
 Psychosedation – N2O – O2 is preferable
 Inferior alveolar NB and Posterior superior alveolar NB – risk of hemorrhage – should
be avoided

58. Management
 Antiplatelet agents
 Aspirin 325mg
 Clopidogrel (75 mg oral OD)
 Ticlopidine (250 mg PO q12 hrs)
 Dipyridamole (75-100 mg oral TD)
 Beta-blockers
 Propranolol(40 mg oral TD)
 Metoprolol (100 mg oral BD)
 Atenolol (50 mg oral BD or 100 mg oral OD)
 Heparin
 Nitroglycerine
 Sodium nitroprusside
 Thrombolytics- Streptokinase 1.5 million units / Urokinase

59. DRUG RELATED EMERGENCIES

60. Drug overdose
 In a dental practice, commonest overdosage>>LA
Predisposing factors for over dosage:
 Patient age/body weight
 Route of administration
 Presence of vasoconstrictor
 Type of local anaesthetic

61. Clinical features
 Confusion, talkativeness, slurred speech
 Muscular twitching, facial tremor
 Headache, tinnitus
 Drowsiness, disorientation
 Elevated BP,HR,RR
 If uncontrolled, generalised tonic clonic
seizures, generalised CNS carbopathy

62. Management
 Administer basic life support
 Administer Oxygen at 10-15L/minute.
 Anticonvulsants, (Midazolam) 2mg, then 1mg.
 Allow recovery to occur
 Summon EMS, in case of continuation of symptoms,
 Intravenous bolus of 1-1.5 ml/kg of 20% ILE solution administered
over one minute. 12.5 ml/kg of 20% ILE over 24 hours in
adults

63. Allergy
• “A hypersensitive state of skin and various mucosa acquired through exposure to a particular
allergen, re exposure to which produces a heightened emergent capacity to react”
• Occurs via expression of IgE in response to Allergen.
CLINICAL FEATURES:
 Pallor, Syncope, Palpitations,
 Tachycardia, Hypotension, Arrythmias, And Convulsions.
 Respiratory Symptoms Include; Sneezing, Cough, Wheezing,
 Tightness In Chest, Bronchospasm, Laryngospasm.
 Skin Is Warm And Flushed With Itching, Urticaria, And
 Angioedema.
 Nausea, Vomiting, Abdominal Cramps.

64. Management
General Treatment
 Maintain airway, administer oxygen
 Monitor vital signs.
Mild Reactions
 Benadryl 50-100mg or Cholpheniramine maleate 4-12 mg IV, or IM.
 Identify and remove allergen.
Severe Reactions
 Epinephrine is drug of choice. Usually prepackaged 1:1,000 in 1mg
 If IV in place titrate 1:1,000 solution to effect.
 Hydrocortisone sodium succinate (Solu-cortef) 100-500mg IV or IM. Dexamethasone (Decadron) 4-12mg IV or IM.

65. Needle stick injury
 Injury made with any sharp instrument.
 Encountered more commonly by the practitioner.
HISTORY
 Details of incident – time, date, place
 Details of injury – location on body, superficial or deep
 Source (the person who used the needle) known or unknown?
 What kind of needle/syringe?
 What, if any, first-aid has been provided?
 Was there visible blood on/in the needle/syringe?
 Immunisation history (specifically tetanus and hepatitis B)
INVESTIGATIONS
 Routine for Hepatitis B, hepatitis C and HIV.

67. Conclusion
 Prompt recognition and efficient management of medical emergencies by a well-prepared
dental team can increase the likelihood of a satisfactory outcome.
 The basic algorithm for managing medical emergencies is designed to ensure that the
patient‟s brain receives a constant supply of blood containing oxygen.

68. References