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Medical emergencies in dentistry phd

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Medical emergencies in dentistry phd

  1. 1. Medical Emergencies In Dentistry - II By CYRIAC JOHN FINAL YR, PART I
  2. 2. • Unconsciousness - Vasodepressor syncope - Postural Hypertension - Acute adrenal insufficiency • Respiratory Distress - Foreign body airway obstruction - Hyperventilation - Asthma - Heart failure and acute pulmonary edema CLASSIFICATON
  3. 3. • Altered Consciousness 1. Diabetes Mellitus - Hyperglycemia - Hypoglycemia 2. Thyroid gland dysfunction 3. Cerebrovascular accident
  4. 4. • Seizure • Drug related emergencies - Drug overdose reactions - Allergy • Chest pain - Angina Pectoris - Acute Myocardial Infarction Sudden cardiac arrest
  5. 5. HYPERTENSION DEFINITION “ABNORMALLY HIGH BLOOD PRESSURE CREATING SIGNS AND SYMPTOMS TO THE PATIENT” RISK FACTORS • ATHEROSCLEROTIC VASCULAR DISEASE • HISTORY OF HYPERTENSION
  6. 6. PRECIPITATING FACTORS • STRESS • FAILURE TO TAKE MEDICATION DIAGNOSIS • HEADACHE • DIZZINESS • TACHYCHARDIA • PALPITATION • CONFUSION • NUMBNESS • LOSS OF LIMB FUNCTION
  7. 7. TREATMENT • SIT UPRIGHT • 100 % OXYGEN • CALL EMERGENCY SERVICES • ANTIHYPERTENSIVE DRUGS PREVENTION • CHECK BLOOD PRESSURE BEFORE PROCEDURE • ASSURE MEDICATIONS • STRESS REDUCTION PROTOCOLS • MONITOR EPINEPHRINE DOSES
  8. 8. ANGINA PECTORIS DEFINITION “A CHARACTERISTIC THORACIC PAIN,USUALLY SUBSTERNAL PERCIPITATED CHEIFLY BY EXERCISE AND MOTION OR A HEAVY MEAL;RELIEVED BY VASODILATOR DRUGS AND A FEW MINUTES REST;AND A RESULT OF A MODERATE INADEQUACY OF THE CORONAL CIRCULATION”
  9. 9. PREVENTION • PROPER MEDICAL HISTORY • THE PAST MEDICAL HISTORY IN DETAIL DENTAL THERAPY CONSIDERATION • AVOID OVER STRESSING THE PT • SUPPLEMENTAL OXYGEN BY A NASAL CANNULA – 3 – 5 L/MIN • PAIN CONTROL DURING THERAPY, APPROPRIATE USE OF LA, SMALLER DOSE WITH MAX. EFFECT – SLOW ADMINISTRATION
  10. 10. • VASODEPRESSOR ADMINISTRATION SHOULD BE MINIMISED IN INCREASED RISK PT • MONITORING VITAL SIGNS • NITROGLYCERINE PREMEDICATION 5MINS BEFORE TREATMENT CLINICAL MANIFESTATIONS • PAIN- SUDDEN ONSET OF CHEST PAIN • DULL ACHING HEAVY PAIN LOCATED SUBSTERNALLY • RADIATION OF PAIN – MOST COMMONLY TO THE LEFT SHOULDR AND ARM, LESS FREQUENTLY TO RIGHT SHOULDER ARM, LEFT JAW, NECK AND EPIGASTRIUM
  11. 11. • PAIN- SUDDEN ONSET OF CHEST PAIN • DULL ACHING HEAVY PAIN LOCATED SUBSTERNALLY • RADIATION OF PAIN – MOST COMMONLY TO THE LEFT SHOULDR AND ARM, LESS FREQUENTLY TO RIGHT SHOULDER ARM, LEFT JAW, NECK AND EPIGASTRIUM
  12. 12. ACUTE MYOCARDIAL INFARCTION • IT IS A CLINICAL SYNDROME CAUSED BY A DEFFICIENT CORONARY ARTERY BLOOD SUPPLY TO A REGION OF MYOCARDIUM THAT RESULTS IN CELLULAR DEATH AND NECROSIS.
  13. 13. PREDISPOSING FACTORS • ATHEROSCLEROSIS AND CORONARY ARTERY DISEASE. • CORONARY THROMBOSIS, OCCLUSION AND SPASM CLINICAL FEATURES • MALES • 5TH AND 6TH DECADE OF LIFE • UNDUE STRESS
  14. 14. SYMPTOMS • PAIN- CRUSHING, CHOCKING, PROLONGED , UPTO 30 MINS • RADIATES TO LEFT ARM, HAND, SHOLDER, EPIGASTRIUM , NECK AND JAW • NAUSEA AND VOMITING, DIZZINESS, PALPITATION • COLD PERSPIRATION • FEAR OF IMPENDING DOOM
  15. 15. SIGNS • RESTLESSNESS • ACUTE DISTRESS • SKIN – COOL, PALE AND MOIST • HEART RATE – BRADYCARDIA TO TACHYCARDIA
  16. 16. DENTAL THERAPY CONSIDERATIONS • AVOID OVER STRESSING THE PT • SUPPLEMENTAL OXYGEN BY A NASAL CANNULA – 3 – 5 L/MIN • PAIN CONTROL DURING THERAPY, APPROPRIATE USE OF LA, SMALLER DOSE WITH MAX. EFFECT – SLOW ADMINISTRATION • VASODEPRESSOR ADMINISTRATION IS A RELATIVE CONTRAINDICATION.
  17. 17. • PSYCHOSEDATION – NITROUS OXIDE AND OXYGEN IS PREFERRED • IT IS STRONGLY RECOMMENDED THAT ELECTIVE DENTAL CARE IS AVOIDED UNTIL ATLEAST 6 MONTHS AFTER MI • MEDICAL CONSULTATION AND ANTICOAGULATION AND ANTIPLATELET THERAPY NEED NOT BE ALTERED • INFERIOR ALVEOLAR NERVE BLOCK AND PSA NERVE BLOCK – RISK OF HEMORRHAGE – SHOULD BE AVOIDED
  18. 18. PREVENTION • PROPER MEDICAL HISTORY • THE PAST MEDICAL HISTORY IN DETAIL • VITAL SIGNS SHOULD BE RECORDED BEFORE AND IMMEDIATELY AFTER DENTAL APPOINMENTS • VISUAL EXAMINATION – PERIPHERAL CYANOSIS, COOLNESS OF EXTREMITIES, PERIPHERAL EDEMA, POSSIBLE ORTHOPNEA
  19. 19. POSTURAL HYPOTENSION “DECREASED BLOOD PRESSURE ASSOCIATED WITH AN ABRUPT CHANGE IN PT POSITION” • ORTHOSTATIC HYPOTENSION
  20. 20. PRECIPITATING FACTORS • RAPID VERTICAL CHANGE IN BODY POSITION IN PERSONS AT RISK • DEHYDRATION • BLOOD LOSS • ALLERGIC REACTION • MI
  21. 21. CLINICAL FEATURES/DIAGNOSIS • PT FEELS LIGHT HEADED UPON RAPID STANDING • LOSS OF CONSCIOUSNESS • VITAL SIGNS SHOWBLOOD PRESSURE LOW PULSE NORMAL OR
  22. 22. TREATMENT AND MANAGEMENT • STOP DENTAL TREATMENT • REMOVE OBJECTS IN MOUTH • RAISE FEET • LOOSEN THE CLOTHING • SUPPLEMNTAL OXYGEN • COOL TOWEL TO FOREHEAD • MONITOR VITAL SIGNS
  23. 23. PREVENTION • DO NOT ALLOW THE PTs AT RISK TO RAPIDLY STAND FROM THE DENTAL CHAIR • ELEVATE THE PATIENTS SLOWLY AND IN STAGES • BE PREPARED TO PHYSICALLY SUPPORT THE PATIENT IF THEY PASS OUT
  24. 24. BACTERIAL ENDOCARDITIS DEFINITION “Infective endocarditis is defined as microbial infection of the endothelial surfaces of the heart or iatrogenic foreign bodies like prosthetic valves other intracardiac devices.”
  25. 25. PREDISPOSING FACTORS • Numbers of bacteria entering the blood • Ability of bacteria to adhere to endocardium • Congenital • Rheumatic and other acquired valvular disease • Prosthetic heart disease
  26. 26. MANAGEMENT • A CONSENT LETTER FROM THE DR OVERLOOKING THE PT-STATING PATIENT IS IS FIT FOR DENTAL PROCEDURES • Early treatment needed to minimize the cardiac damage. The usual treatment is intravenous penicillin plus gentamycin for 2 weeks or more viridians streptococci is the causative orgm
  27. 27. DENTAL TREATMENT UNDER - LA Clinical Situation Drug Regimen Patients not allergic to pencillin Amoxillin ADULTS Oral amox 3g 1hr. Before procedure CHILD <5yrs : oral amox-250mg 1 hr. B.Pr 5-10yrs : oral amox-500mg 1 hr. B.Pr >10yrs : use adult dose
  28. 28. Patient allergic to pencillin Clindamycin ADULTS Oral clindamycin 600mg 1 hr before pr. CHILD <5 yrs- Oral Clindamycin 150 mg 1hr. Before pr. 5-10 yrs- oral clindamycin 300mg 1 hr. bef pr. <10 yrs – Use adult dose
  29. 29. UNDER GA CLINICAL SITUATION DRUG REGIMEN Patient not allergic to penicillin Amoxicillin ADULTS i.v. amox 2g administered upon attainment of GA and immediately bef pr. CHILD <5yrs-i.v. amox 250mg administered upon attainment of GA 5-10yrs-oral amox 500mg administered 1 hr. bef pro. >10yrs- Use adult dose 2g administered before procedure
  30. 30. Treatment needing Antimicrobial prophylaxis in pts at risk of IE • Extractions • Sub gingival procedures – Probing/card placement. • Oral/Periodontal implant surgery & flap surgery. • Endodontics beyond the root apex. • Sialography • Intraligamental LA • Rubber dam matrix/Wedge placement
  31. 31. Procedure in which antimicrobial prophylaxis NOT reqd in persons at risk of Infective Endocarditis • Dental Radiography • Endodontics beyond apex. • Exfoliation of primary teeth. • Impression taking. • Non surgical procedures that not have bleeding. • Abscess incision and drainage. • Suture removal, orthodontic band removal
  32. 32. MEDICAL EMERGENCIES DUE TO FUNCTIONAL CAUSES IATROGENIC CAUSES ARE MAINLY • NEEDLE BREAKAGE • SWALLOWING OF DENTAL & SURGICAL MATERIALS • INJURY TO SOFT TISSUE • INFECTION
  33. 33. NEEDLE BREAKAGE MAIN CAUSE OF NEEDLE BREAKAGE IS DUE TO • USING INAPROPRIATE NEEDLE SIZE FOR PROCEDURES • INJECTING WITHOUT STABILIZING THE SYRINGE BY HOLDING THE THE HUB OF THE NEEDLE TREATMENT AND MANAGEMENT • INFORM AND ENSURE THE PATIENT ABOUT THE INCIDENT • WITH PROPER CARE AND ASSISTANCE,SURGICALLY REMOVE THE THE BROKEN SEGMENT • PROVIDE POST SURGICAL INSTRUCTIONS AND MEDS
  34. 34. SWALLOWING OF DENTAL AND SURGICAL MATERIALS TREATMENT AND MANAGEMENT • INFORM AND ENSURE THE PT • INDUCE VOMITING • GASTRIC LAVAGE • MILK THERAPY
  35. 35. INJURY TO SOFT TISSUES Causes Accidental slipping of instruments Inappropriate surgical practices Treatment and management Inform and ensure the patient Control the bleeding if present Give appropriate medications and instruction
  36. 36. • Infection Causes • Unsterile instruments • Unhygienic practices • Unsterile environment(clinical surrounding) • Using one instrument for multiple procedures in diff pts without disinfection and sterilization Management • Sterilize every instrument before starting treatment on a new patient • Keep the clinical environment clean and sterile
  37. 37. DRUG OVERDOSE REACTIONS OVERDOSE IS A CONDITION THAT RESULTS FROM EXPOSURE TO TOXIC AMOUNTS OF A SUBSTANCE THAT DOES NOT CAUSE ADVERSE EFFECTS WHEN ADMINISTERED IN SMALLER AMOUNTS. DRUGS AND ADVERSE REACTIONS • LOCAL ANAESTHETIC • ANTIBIOTICS • ANALGESICS • SEDATIVE HYPNOTICS
  38. 38. • LOCAL ANAESTHETICS ESTERS ALLERGY – common, especially with topical anesthetics, manifested as localized erythema and edema. Overdose – unlikely with esters, unless genetic deficiency present Side effects – rare sedation or drowsiness Management – antidote to la overdose is phentolamine mesylate
  39. 39. • AMIDES ALLERGY - MOST CLINICAL REPORTS PROVED ALLERGY TO BE PSYCHOGENIC RXN, OVERDOSE OR ALLERY TO OTHER COMPONENT OF SOLUTION OVERDOSE – CNS DEPRESSION MANIFESTED AS DROWSINESS, TREMOR, TONIC CLONIC SEIZURES SIDE EFFECTS – RARE, SEDATION MOST COMMON
  40. 40. • ANTIBIOTICS ALLERGY – HIGH ALLERGIC POTENTIAL TO MANY ANTIBIOTICS MANIFESTED CLINICALLY OVER ENTIRE SPECTRUM OF ALLERGIC PHENOMENA. OVERDOSE – VIRUALLY NON EXISTENT WITH PENICILLIN SIDE EFFECTS – RARE GI UPSET – MOST COMMON
  41. 41. • ANALGESICS NON OPIOID ALLERGY – HIGH ALLERGY POTENTIAL (ASPIRIN) OVERDOSE – COMMON SALICYLISM OPIOIDS ALLERGY – UNCOMMON OVERDOSE - COMMON, MANIFESTED AS CNS DEPRESSION AND RESPIRATORY DEPRESSION SIDE EFFECTS – MOST COMMON ADR, MANIFESTED CLINICALLY AS NAUSEA, VOMITING, ORTHOSTATIC HYPOTENSION
  42. 42. • SEDATIVE HYPNOTICS BENZODIAZEPINES OVERDOSE – CNS DEPRESSION MANIFESTED AS OVER SEDATION SIDE EFFECTS- PROLONGED DROWSINESS INHALATION SEDATION (N20-02) OVERDOSE – COMMON, MANIFESTED AS OVER SEDATION SIDE EFFECTS – MOST COMMON AREA MANIFESTED AS NAUSEA, VOMITING
  43. 43. • MANAGEMENT MANAGEMENT OF OVER SEDATION FOCUSES ON DEREASE IN PERCENTAGE OF N2O THROUGH AN INCREASE IN THE VOLUME OF FLOW OF O2 COUPLED WITH THE STEPS OF BLS. P-A-B-C UNTIL THE PT REGAINS CONSCIOUSNESS.
  44. 44. • Prompt recognition and efficient management of medical emergencies by a well prepared dental team can increase the likelihood of satisfactory outcome. • The basic aim for managing medical emergency is to ensure that the pts brain receives constant supply of blood containing oxygen. Conclusion
  45. 45. • Medical emergencies in dental office: Stanley F Malamed • Mark greenwood dental emergencies References

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