Emergencies in dental clinic

How to deal
An emergency is

 medical condition that requires immediate attention and successful

management
 These are the life-threatening situations of which every dental
practitioner must be aware so
 that unwanted morbidity can be avoided.
 Emergencies can be prevented to a certain extent by recording a
detailed medical history, doing a complete physical examination,
and thorough patient monitoring
 Basic Principles Of Management Of Medical
Emergencies

 Basic life support (BLS) measures and cardiopulmonary

resuscitation (CPR).
 This is done by following the basic principles:
 Position (P), Airway (A), Breathing (B), Circulation (C),
and Definitive therapy (D)
The basic positions to manage an emergency are

 supine position,
 Trendelenburg position,
 semi-erect position
 Maintaining a patent and functioning airway
is the first and important procedure in
managing an emergency
 This is achieved usually by the head tilt-chin lift
maneuver.
 The next priority is to check for the presence of adequate breathing
is assessed by the
 look-feel and listen-to technique
 If spontaneous breathing is not evident then rescue breathing should
be initiated immediately
 either by the mouth-to-mouth technique or the bag-valve-mask
technique.
Next step

 circulation is assessed
 by palpating the carotid pulse at the region of the
sternocleidomastoid muscle, radial artery
In case of absence of pulse

 CPR is initiated immediately.

 When airway, breathing, and circulation are maintained,
 definitive treatment is initiated. Definitive therapy involves the
 administration of an ideal drug to relieve symptoms.
Basic life support (BLS)
Syncope

 general term referring to a sudden, transient loss of

consciousness that usually occurs secondary to a period of
cerebral ischemia
 Types
 1) psychogenic factors
 2) non psychogenic
 NB:Normal adult RR is 12-20 breaths/min and child RR is 20-30 breaths/min.
 The psychogenic factors for syncope are
Fright, Anxiety, Emotional stress, undesirable
news, Sight of blood/surgical/dental
instruments
 Non -Psychogenic factors are Erect sitting or
standing, posture, starvation or a missed meal,
Exhaustion, Poor physical condition , crowded
environment.
presyncope

 Before going into syncope

 patient will have certain signs and symptoms such as Warm feeling
in face and neck, pale or ashen coloration, sweating, feels cold,
abdominal discomfort, lightheadedness or dizziness, mydriasis
(Pupillary dilatation.), Yawning, Increased heart rate, a slight
decrease in blood pressure
During syncope

 the patient loses consciousness. Generalized muscle

relaxation will happen, Bradycardia (Weak thready
pulse.,Seizure (Twitching of hands, legs, and face.),
the post syncopal

 Once the patient recovers during the post syncopal period

there will be a Variable period of mental confusion, Heart
rate increases (Strong rate and rhythm.), Blood pressure
back to normal levels.
 Pathophysiology of syncope

 When the body experiences Stress

 the Catecholamines( include dopamine, epinephrine (adrenaline), and
norepinephrine (noradrenaline). get released into the blood, this is the body’s
response to stress it is known as the “ fight or flight “ response. Increased
catecholamines will lead to changes in tissue blood perfusion and decrease peripheral
vascular resistance and increase the blood flow to many tissues especially the skeletal
muscles for the muscular action to take place. If the expected muscular action takes
place the muscle will pump the blood back to the heart so the blood pressure remains
at a base level so the signs of syncope don’t occur. when the muscular activity doesn’t
take place, the patient remains static in the dental chair. The blood starts pooling in
the periphery which leads to decreased cardiac output followed by decreased in
circulating blood volume and decreased arterial BP this ultimately leads to decreased
cerebral blood flow
 What triggers catecholamine release?
 Splanchnic nerve stimulation is the physiological stimulus
for catecholamine secretion. Stimulation of the splanchnic
nerves results in the release of ACh from nerve endings in the
adrenal medulla.
 Management
 Check ABC Assess & open airway (head tilt &chin lift); assess airway patency&
breathing; assess circulation (palpation of carotid pulse).
 Lie flate , elevate legs, untighten clothes once awake offer glucose in tea or drink
 Lf not
 Move on to definitive management administer O2 Monitor vital signs( not mostly
needed). Administer aromatic ammonia vapor which I a respiratory stimulant that helps
to increase breathing and muscular movement. Administer atropine 0.5mg IM if
bradycardia persists. Once the patient recovers dental treatment should be postponed
 Atropine inhibits the effect of acetylcholine by complexing the acetylcholine receptor on the other
side of the cleft, subsequently inhibiting the binding of acetylcholine. If atropine does not allow
acetylcholine to bind to the acetylcholine receptor, then the effects of acetylcholine are inhibited.
 Mechanism Of Action
 Atropine competitively blocks the effects of
acetylcholine, including excess acetylcholine
 Atropine increases the heart rate and improves
the atrioventricular conduction by blocking the
parasympathetic influences on the heart.
Postural Hypotension

 The predisposing factors of postural hypotension are

Drugs such as anti-hypersensitive, opioids and histamine
blockers, Prolonged period of recumbency or
convalescence, Inadequate postural reflex, Late-stage
pregnancy, Advanced age,
Pathophysiology of postural hypotension

 When the patient is in the supine position the

blood pressure is equally distributed throughout
the body When the body alters the position to Semi
supine the BP decreases by 2mm Hg for every 1
inch when the patient moves into supine to upright
the Influence of gravity in CVS is increased.
Management

 The patient must be placed in a supine position with feet

elevated.
 ABC Assessed following which oxygen is administered at
the rate of 8-15ml per minute. patients vital signs are
monitored and chair reposition should be done slowly
Foreign Body Airway Obstruction

 due to accidental slippage, aspiration of foreign objects, or

laryngeal spasm.
 Usage of Rubber dam, Gauze, Suction, Magill’s intubation
forceps, Ligature using dental floss Can help in preventing
the intraoral objects from slipping inside the airway
Management

 If the object is visible with the help of the assistant place

the
patient in a supine position or Trendelenburg position, the
object is retrieved using Magill intubation forceps, in the
absence of an assistant instruct the patient to bend over the
arm of the chair with their head down and Encourage the
patient to cough to expectorate the object
 If it fails Kneel or stands behind the victim and wraps arms around
the victim’s waist and makes a fist with one hand, Place the thumb
side of the fist against the victim’s abdomen
Establishing an emergency airway –
Non invasive procedures

Invasive procedures
Asthma

 chronic inflammatory disorder of the airways it is

characterized by recurrent and often irreversible airflow
limitations due to underlying inflammatory processes
 Confirm that they have taken their most recent
scheduled dose of medication,
 The patient’s metered-dose inhaler bronchodilator
should be on hand, Procedure should be done late
morning/afternoon,
 can be triggered by many things, including dust, traffic
fumes, pollen, stress and even the weather.
 An asthma attack occurs as aresult of being exposed to
an asthma trigger, which causes the small airways (the
bronchi and bronchioles) become narrower, or
constricted, making breathing more difficult
Management

 Sit the casualty upright, leaning on a chair, if necessary

(the dental chair is ideal). Help them to use their
inhaler. (It is much easier to administer the drug
successfully if they can do this themselves). Two “puffs”
should be administered initially,
 (the dose of salbutamol is 100mcgper puff) but this
can be repeated every few minute if the attack does not
ease
The early use of a spacer device
 inhaler should be administered via the spacer one puff at a time,
inhaled separately using Tidal breathing.

 according to response, give another puff every 60 seconds up to a

maximum of ten puffs
 Oxygen must also be administered
 If the episode continues, epinephrine is administered IM 0.01mg/kg
up to 0.5 mg. When the episode subsides discharge the patient and
postpone the dental treatment if it continues activate EMS
‫تلخيص اكتر‬
If the pat cannot breath , cyanosis , confused , decrease level of consciousness >>>>>
Management of hyperventilating patients
 • Assess airway breathing and circulation; identify any disability
 • Reassure patient
 • Encourage patient to decrease respiratory rate slowly
 • If there is obvious sympathetic overactivity, as shown particularly
 by tachycardia or arrhythmias, a cardiologist’s opinion should be
 obtained, as treatment with a beta-blocker may be necessary
 • Defer dental treatment until medical assessment has taken place
Diabetes Mellitus

 Diabetes is the most common endocrine disorder. It is

marked by high levels of blood glucose resulting from
defects in insulin production, insulin action, or both
Hyperglycaemia

 Clinical symptoms include thirst, increased urine output and

dehydration, and also, there may be hypotension, progressive
reduction in level of consciousness, coma or cessation of urinary
output in severe cases.
 Management
 Primary assessment and resuscitation , is to secure the airway,
breathing and circulation. Then transport to a hospital facility.
Hypoglycaemia

 Clinical symptoms of hypoglycaemia include sweating,

hunger, tremor, agitation, with progressive drowsiness,
confusion and coma. Assume any diabetic with
impaired consciousness has hypoglycaemia until
proven otherwise
 Low blood sugar is called hypoglycemia. A blood
sugar level below 70 mg/dL (3.9 mmol/L) is low and
can harm you.
 If the patient is conscious and cooperative, offer the
patient 15–20 g of quick-acting carbohydrate; for
example, , one bottle (60 ml) Glucojuice or 150–200 ml
pure fruit juice.
 Chocolate is no longer recommended for the treatment of
hypoglycaemia because its fat content slows the
absorption of quick-acting carbohydrate
 In unconscious patients, 50ml of dextrose is given in 50%
concentration
 or 1mg glucagon intravenously, or give 1ml glucagon intramuscular
almost any body site. Paediatric dose of glucagon 0.5 ml or ,<8 yrars
old or less than 25 kg
 Following the treatment, the signs and symptoms of hypoglycemia
should resolve in 10 to 15 minutes, once stabilized, the patient is
transported to a hospital for definitive care and observation. Postpone
the dental procedure. When the condition doesn’t cease activate EMS
Epileptic seizures
Epileptic seizures

 All patients with epilepsy should have a personalised care plan,

 Thiopental 50 mg 2.5-5% or valium iv

 Buccolam contains midazolam hydrochloride 5 mg/1 ml in pre-

filled oral syringes of 2.5 mg, 5 mg, 7.5 mg and 10 mg
 Stop any procedures dismiss the patient
Hypertension

 Defined as blood pressure Greater Than 140/90

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54
 To recapitulate: Questions for the dentist to consider when deciding on
 dental care are:
 What is the actual BP number?
 Is therapy elective or emergent?
 Will the procedure be long or invasive?
 What is the health of the patient?
 Is there any advice from the patient’s physician
 ASA Class I. A normal healthy patient
 ASA Class II. A patient with mild systemic disease
 ASA Class III. A patient with severe systemic disease
 ASA Class IV. A moribund patient who is not expected to survive without
 the operation
 <160/100 No modification in ttt plan
 Considering pat status, age, oral health
 >160/100* Repeat measurement
If lowered or within written guidance from a physician, proceed
If confirmed, no elective dental treatment and the patient should seek consultation with a physician

Emergency Dental Care:

Repeat measurement
If lowered or within written guidance from a physician, proceed
If confirmed systolic pressure 160–180 mmHg and/or diastolic pressure 100–109 mmHg where dental symptoms and pain
contribute to hypertension, initiate emergency care with blood pressure monitoring every 10 to 15 minutes during procedure;
consider anxiety reduction techniques
If confirmed systolic pressure >180 mmHg and/or diastolic pressure >109 mmHg, seek consultation with a physician before
proceeding
 One cartridge of anesthetic containing 1:50,000 epinephrine;
Two cartridges of anesthetic containing 1:100,000 epinephrine; or
Four cartridges of anesthetic containing 1:200,000 epinephrine

 Not recommended to uncontrolled patients

Hypertension

Management
 Control BP before elective treatment
 Reasonable control of severe hypertension before emergency treatment
 Medical consult before treatment for uncontrolled hypertension

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Angina pectoris

 is an acute coronary syndrome associated with transient ischemia to the myocardium.

 Hypoxia results from diseases and conditions which lead to atherosclerosis and obstruction
of coronary arteries by fatty deposits that limits and/or impairs coronary blood flow.
 Precipitating factors that increase cardiac oxygen demand in the presence of decreased
perfusion of the myocardium include physical exertion, emotional stress, cold, recent meal.
Unstable angina pectoris may occur spontaneously at rest
 Prevention by decrease pain and anexcity
 Anaesethia with VC according to pat physical status
• Symotoms
• Chest pain that feels like pressure or indigestion.
• Pain that radiates to your left shoulder or down your left arm.
• Shortness of breath.
• Dizziness.
• Nausea.
• Exhaustion.
 occurs chiefly as
 i. stable angina
 a type of chest pain that happens when your heart muscle needs more
oxygen than usual but it's not getting it at that moment because of heart
disease
 ii. unstable angina.
 Chest pain with no effort exerted
 should not implement the Procedures without prior consultation with the appropriate
primary or specialist care provider(s) if the patient/history or present condition appears
suggestive of unstable angina and/or if the patient/client is taking an antiplatelet agent
(other than low-dose ASA) — as often happens with cardiac stenting — or an
anticoagulant2 (e.g., warfarin3 or a direct oral anticoagulant), which increases risk of
bleeding.
 may postpone the Procedures pending medical advice if the patient
 a. is experiencing symptoms suggestive of stable angina and is not receiving routine
medical care
 b. has not complied with pre-medication, such as nitrates, as directed by the prescribing
physician
 c. has recently changed significant medications, under medical advice or
 otherwise
 Administer nitroglycerine – if patient’s prescription not available – administer 0.3/0.4 mg
sublingually.
 If pain persists five minutes after nitroglycerine dose,
 repeat administration.
 If still no response,
 repeat nitroglycerine and administer oxygen 2/4 L/min
 If angina does not subside – concerned that myocardial infarction is developing. Transfer
to emergency room
Myocardial Infarction

 Myocardial infarction is caused by abrupt anoxia to a portion of the heart resulting in

myocardial tissue necrosis.
 Heart Attack (Myocardial Infarction) A heart attack (medically known as a
myocardial infarction) is a deadly medical emergency where your heart muscle
begins to die because it isn't getting enough blood flow. This is usually
caused by a blockage in the arteries that supply blood to your heart
 Anoxia results from conditions that lead to the formation of atherosclerotic plaques. In
later stages, atherosclerotic plaques may become disrupted and contribute to thrombus
formation. Atherosclerotic plaques and thrombi impair blood flow to large and medium-
sized arteries of the heart. History of cardiovascular diseases, diabetes mellitus, and
cerebrovascular disease increases the overall risk of perioperative MI
Strock ‫س^^كته^ دماغية‬

 Facial weakness
 Arm weakness
 Problems in speech
 Management
 • Assess, clear airway and check breathing
 • Check pulse and capillary refill
 • Reassure the patient
 • Give high-flow oxygen 15l/min
 • Call ambulance
 • Defer dental treatment
Adrenal crisis

 The adrenal glands (AGs), part of the body’s endocrine system, are two small organs
located on top of the kidney.
 Two parts : cortex and medulla
 Cortisol is secreted from the cortex
Cortisol is involved in

1. the mechanisms of adaptation of the organism to stress maintaining homeostasis;

2. - it has anti-inflammatory and immunosuppressive effect,
3. it is responsible for mobilizing fatty acids from adipose tissue,
4. it maintains vascular reactivity, it promotes the liver’s protein synthesis via
neoglycogenesis,
5. it increases gycemia
6. it inhibits bone formation and delays healing
 . AGs insufficiency can be primary
 known as Addison’s disease (AD),

or secondary, resulting from long-term glucocorticoids

 treatments or more infrequently from pituitary disorders . AC is common mainly in the
primary type of the diseas
Addison’s disease
 The most frequent etiology of AD is the autoimmune destruction of the Ags
 Other causes can be involved in primary adrenal insufficiency such as infections (sepsis,
tuberculosis, etc.), adrenal hemorrhage, sarcoidosis, lymphoma etc
 Signs and symptoms of AD vary considerably, from generalized weakness and malaise to
weight loss with/without anorexia, nausea and vomiting, diarrhea or constipation,
abdominal pain, hypotension, electrolyte imbalance (from metabolic acidosis to
hyponatremia and hyperkalemia), vitiligo and other autoimmune lesions, reduced pubic
and/or axillary hair,
 normal ranges of cortisol are:
• 6 to 8 a.m.: 10 to 20 micrograms per deciliter (mcg/dL)
• Around 4 p.m.: 3 to 10 mcg/dL
 Treatment of AD includes lifetime glucocorticoid (hydrocortisone)
Management of patients with AD in dental
clinic
 For Miller et al 2001., general anesthesia, infections, stress, and pain augment the risk of
AC in predisposed patients
 ‫و بالتالي االسنان ممكن تسبب مشكلة نتيجه الوجع او الخوف او العدوي‬
Important

 As for the patients’ ability to tolerate dental care,

dentists are required to apply a stress-free protocol
in pre-, per- and post treatment and to make sure of
long-acting anesthesia and postoperative pain
control
 In a classification adopted by the American Dental
Association (Patton and Glick, 2016), Miller et al.2001
classified the risk, from dental procedures, for patients
with adrenal insufficiency into 3 categories, negligible,
mild, and moderate/major risks
 If it happened on chair
 If the patient develops adrenal crisis, call 999 immediately,
 if the patient’s emergency hydrocortisone injection kit is available,
administer intramuscular (IM) hydrocortisone. The recommended dose,
which should be stated on the patient’s adrenal crisis letter, depends on the
patient’s age:
 Adults: 100 mg
 Children six years of age or older: 50–100 mg (use clinical judgement
depending on the age and size of the child)
 Children one to five years of age: 50 mg
 Infants up to one year of age: 25 mg.
‫تلخيص‬

Dental management of the patient with Addisonian crises

- interrupt dental procedure,

- place the patient in dorsal decubitus and contact with the corresponding medical
emergency service.
- Until medical help arrives, the patient should be administered oxygen (5-10 liters/min).
- If the patient is unconscious, he should be placed in dorsal decubitus with the legs raised,
- If an adrenal cause is suspected, 100 mg of hydrocortisone should be administered
intravenously or intramuscularly, within 30 seconds if possible, and two hours later,
another 100 mg of hydrocortisone dissolved in saline for intravenous or intramuscular
injection should be provided
 Doses of drugs equivalent
to 20 mg of cortisone

 Hydrocortisone 20 mg
 Prednisone 5 mg
 Dexamethasone 0.75 mg
Anaphylactic shock
 Anaphlaxis
 Pathophysiology
 In IgE-mediated anaphylaxis, the first contact of the allergen with the host
results in the production of specific IgE antibodies by plasma cells – a
process called sensitization.
 Subsequent exposure to the allergen causes cross linking of the IgE
antibodies and aggregation of their receptors
 This results in the
 release of preformed mediators (such as histamine, tryptase carboxypeptidase
A, proteoglycans, chymase and TNF-a) and newly synthesized mediators
(such as leukotrienes, prostaglandins, TNF-a, platelet-activating factor)
 genetic variation has a role in the severity of the response
to the allergen in sensitized individuals.
Anaphylactoid reactions (non-allergic anaphylaxis)

 do not require previous exposure to the allergen. There are

a number of mechanisms implicated in the process and
these vary depending on the agent. Mechanisms include
direct activation of mast cells and basophils to cause
histamine release, as well as activation of the kallikrein-
kinin system and complement and clotting cascades.
 Most common ch.ch
 Urtecaria and angioedema
 Shortness of breath
 Hypotension systole less than 90
 For a diagnosis of anaphylaxis, there should be an acute onset
(minutes to hours) of two or more of: skin-mucosal involvement;
respiratory compromise; hypotension and associated symptoms; and
persistent gastrointestinal symptoms
 ‫ مهمه ازاي نفرق بين‬vasovagal aatack and
vasovagal attack in anaphylasis
 Vasovagal reactions feature hypotension, nausea, vomiting, diaphoresis
and bradycardia
 in anaphylaxis it is usually tachycardic, although it can also be
bradycardic, and therefore this may not be a reliable distinguishing
factor
 Other features in the favour of a vasovagal reaction include the rapidity
of onset, maintenance of a central pulse and prompt response to supine
positioning
Solu cortef vial Pirafen amp 5mg/1ml
100/2ml

Sultan 50 mg cap

allergyl tab 4mg

example of how to place an unconscious
patient into the lateral recovery position – always ensure that the chin is
in an elevated position to maintain airway patency