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MEDICAL
EMERGENCIES
CONTENTS
• Introduction
• Objectives
• Prevention of medical emergency
• Preparation for emergencies
• Recommended dental office emergency drugs
• Suggested dental office emergency equipment
• Basic life support
• Commonly occurring medical emergencies
• Conclusion
• Refrences
• Dorland’s medical dictionary, defined medical
emergency as a sudden, urgent, usually unforeseen
occurrence requiring immediate action.
• Medical emergencies in dental practice are not an
uncommon occurrence, it invariably occurs when least
expected.
• Simple protocols that are followed will help the dentist
to be in control with situation.
INTRODUCTION
OBJECTIVES
❖Recognize a medical emergency.
❖Asses and manage various life-threatening medical
emergencies.
❖Contempt in basic life support (BLS)
❖Know what equipments and medications be kept in an
emergency kit.
PREVENTION OF MEDICAL
EMERGENCY
• Complete medical and dental history
• Physical examination
• Medical consultation if required
• Patient monitoring
PREPARATION FOR
EMERGENCIES
• A functioning dental office emergency team.
• The ability to properly perform basic life
support.
• Access to emergency medical assistance.
• The availability of emergency drugs and
equipment.
Malamed SF. Emergency Medicine in Pediatric Dentistry: Preparation and Management.
C.D.A. journal. 2003; 31.
RECOMMENDED DENTAL OFFICE EMERGENCY
DRUGS
• The level of medical care which is used
for victims of life-threatening injuries until
they can be given full medical care at a
hospital.
BASIC LIFE SUPPORT
Regardless of emergency, discontinue
dental procedure immediately & follow
pattern of
1. Circulation evaluation to
ensure that the vital organs
are being supplied adequately.
2. Airway patency and
maintenance.
3. Breathing assessment of the
child.
4. Definitive treatment.
1
2
4
3
Basic Life Support/Cardiopulmonary Resuscitation. American Academy Of
Pediatric Dentistry, 2015.
Circulation
Airway
Management
Head
tilt chin
lift
Jaw
thrust
Breathing
▪ Pinch nose
▪ Take normal breath
▪ Place lips over mouth
▪ 1 breath every 6 sec
▪ Blow until chest rises
▪ Allow chest to fall
▪ Repeat
CPR FOR CHILDREN
COMMONLY OCCURRINGMEDICAL EMERGENCIES
1. Allergy or Allergic reaction
2. Anaphylaxis
3. Acute asthmatic attack.
4. Hypoglycemic shock
5. Airway obstruction
6. Seizures
7. Syncope
1. ALLERGY / ALLERGIC REACTION
• Allergy-hypersensitive state results from exposure to allergen.
• Range from immediate-life threatening condition seen within
seconds or delayed type reaction which may manifest hours
or days after exposure.
• Urticaria-itching
• Angioedema
• bronchospasm,
• Conjuctivitis and
watering of eyes
• Hypotension
2. ANAPHYLAXIS
• They pose greatest risk to the pediatric patient and is
of greatest concern to dental staff.
• Result from drug administration or reaction to an
allergen (impression material or other materials)
• Most life threatening and dramatic allergic reaction.
• Death can occur in minutes if not treated
appropriately.
• Reactions affect skin, smooth muscle, respiratory and
cardiovascular system
• Anaphylactic shock occurs when consciousness lost as
result of hypotension from an anaphylactic reaction.
• Symptoms begin with skin, eyes, nose then GI system,
respiratory system, finally CVS symptoms develop.
• Prompt therapy can stop reaction
Cardiac arrest
Cardiovascular shock
Including pallor,
sycope, tachycardia,
weak pulse-syncope
Respiratory-
sneezing,
coughing,
wheezing,
Rhinitis
bronchospasm,
laryngospasm
Skin-
Urticaria-itching
Angioedema
Rash Gastrointestinal-
Nausea
Vomiting,
Abdominal cramps
MANAGEMEN
T
Acute Reaction:
• Basic Life Support
• Epinephrine, injection i/m,1:1000 in 1 mg vials
• If no improvement then 0.3-0.5mg im/sc repeat every 5-10
minutes. Pediatric dose- 0.2-0.3 mg
• Oxygen is administered continuously.
• Corticosteroid-high dose is given if asthma, edema or
pruritis.
• Isotonic solutions for hypotension
• Beta-adrenergic agonist in bronchospasm
• Activate EMS (Emergency life support)
3. ACUTE ASTHMATIC
ATTACK
• Generalized contraction of smooth muscles of bronchi
and bronchioles.
• Characterized- increased irritability of tracheo bronchial
tree to various stimuli including pollen, stress, cold,
upper respiratory tract infections, animal fur.
• Bronchospasm, mucosal edema and intra luminal
secretions lead to airway obstruction. Triggered by
emotional stress and anxiety during the course of
treatment.
Recognition➢ Attack may be very mild or present
as STATUS ASTHAMATICUS
➢Expiratory or inspiratory Wheezing
➢ Nonproductive Cough
➢ Diaphoretic
➢ Cyanosis of nail beds
➢ Chest tightness
➢ Chest congestion
➢ Fatigue
➢ Panic, Anxious, confused.
➢Thick stringy mucous at
termination of intense coughing
TREATEMEN
TTreatment:
➢ Discontinue dental treatment.
➢ Sitting position is most comfortable
➢ Use of bronchodilators supplemented with oxygen
and hydration. Supplemental oxygen at 10L/min.
➢ Patient to use his own inhaler, if available with him
➢ Adrenaline 1:1000, 0.15 ml SC/IM
➢ Corticosteroids if required.
➢ If no improvement call EMS
▪ Atropine and antihistaminic drugs also tend to dry
secretions.
▪ Aspirin should be avoided in asthmatics as this can make
the conditions worse in certain patients.
▪ A preoperative history of
✓Severity
✓Medicines required
✓Degree of control
✓Recent visit to emergency room to be taken.
4. AIRWAY OBSTRUCTION
May be caused by-
✓ Swelling of neck owing to infection or trauma
✓ Tumors growing in the air passage
✓ Unconsciousness, causing tongue to fall posteriorly
✓ Obstruction from a foreign body
Obstruction from a foreign body may occur in……..
• Waiting room owing to food or partial denture
• In the operatory room from various oral surgical
instruments, materials, tooth or vomitus.
• In a restaurant (café coronary)
More likely to occur when consciousness is reduced
Recognition:
• Disappearance of foreign body from oral cavity + signs of
laryngeal and bronchial irritation. Consider to have passed into
respiratory passage until proved other wise.
Partial obstruction:
• Gag, choking, coughing or wheeze in an attempt to eject object.
Advise radiographs of chest & abdomen to confirm location.
Complete obstruction:
• No noises are made although patient is attempting to cough or
talk, showing signs of choking, suprasternal & intercostal
retraction
• If foreign body located in trachea or bronchi. Should be referred
immediately for removal by bronchoscopy or thoracotomy.
SIGNS AND SYMPTOMS-
• First Phase (1-3 min) : Conscious, universal chocking,
struggling, paradoxical respirations without air movement or
voice, increased BP & Heart rate.
• Second Phase (2-5 min) : Loss of consciousness, decreased
respiration, BP, heart rate.
• Third Phase (>3-5 min) : Coma, absent vital signs, dilated
pupils.
PREVENTION
• Rubber dam
• Oral/ throat packing (used in sedation or GA)
• Ligature (small instruments secured by tying)
TREATMENT-
1. Lean patient over chair & pound firmly on back try to
dislodge foreign body (small children may be held upside
down by legs & sharp blows rendered to back).
2. If unsuccessful. Keep patient supine on floor/Trendelenburg
position if in dental chair, with head to side and mouth open.
Middle and index fingers should be placed into pharynx and
swept laterally in attempt to remove object.
3. Try to remove object using laryngoscope and Magill
forceps if possible
4. Consider Heimlich procedure (1975): Procedure takes
advantage of remaining air within lungs and by
forcefully compressing the lungs, increases air pressure
within trachea, thus ejecting the offending bolus out.
(like a “cork from a champagne bottle”) (avg. airflow
rate of 205 L/min and pressure 31mm Hg, expelling an
avg. volume of 0.94 L of air in approx. ¼ sec).
5. HYPOGLYCEMIA
• Condition of acutely decreased blood sugar. Life
threatening- more critical than hyperglycemia in emergency
situation. Must be treated rapidly.
• Children suffer from diabetes mellitus type 1.
• Blood (venous) glucose level falls to < 50mg/100ml in
adults & <40mg/100ml in children.
• CAUSES- Intake of too little food, Impaired gastric
emptying. Exercise Is attempted but no reduction in insulin
dose.
Signs And Symptoms-
• Terminate procedure.
• For conscious patient, glucose/ carbohydrate to be given in
3-4 ounces (1ounce= 28gms) every 5-10 min until
symptoms disappear.
• For unresponsive conscious patient, Glucagon 1mg IV/IM
or 50ml of 50% dextrose IV over 2-3 mints.
• Oral-paste or drink.
• Perform BLS.
• Activate EMS.
6. SYNCOPE
• Sudden, transient loss of consciousness that usually
occurs secondary to a period of cerebral ischemia.
• Predisposing factors-
1. Psychogenic factors- Fright, anxiety, emotional stress,
pain, site of blood
2. Non- psychogenic factors- Erect sitting or standing
posture, hunger from dieting or a missed meal,
exhaustion, poor physical condition, male gender.
PATHOPHYSIOLOGY-
• Dilation of blood vessels in skeletal muscle and
splanchnic region.
• A fall in peripheral resistance with decreased venous
return to the heart. This leads to fall in arterial pressure.
• Vagal reflexes are activated, causing bradycardia,
reduction in cardiac output, further reduction in BP, all
leading to decreased cerebral perfusion.
VASOVAGAL ATTACK- rare entity in children as:
• Children keep moving their extremities
continuously.
• The parasympathetic tone in a child is higher.
• Children are more expressive.
Clinical manifestations-
EARLY
• Feeling of warmth
• Loss of color, pale.
• Heavy perspiration
• Reports of feeling bad
• Nausea
• BP slightly lower
• Tachycardia
LATE
Pupillary dilation
Yawning
Hyperpnea
Cold hands and feet
Hypotension
Bradycardia
Visual disturbance
Dizziness
Loss of consciousness
EMERGENCY MANAGEMEMT-
First step is PREVENTION-
• Proper positioning
• Anxiety relief
• Dental therapy consideration
Second step is MANAGEMENT-
• Discontinue treatment
• Assess the level of consciousness: Patient’s lack of response to
sensory stimulation
• Activate the office emergency system: Call for help and
emergency drug kit should be available
• Position of patient: Proper supine position with feet elevated.
• Assess airway and circulation
• Provide definitive care: Give oxygen, monitor vital signs, No
drug treatment usually indicated.
• Also loosen clothing if binding & cold towel at back of neck
7. SEIZURES
• Group of disorders of cerebral functions characterized by
chronic, recurrent, paroxysmal discharge of cerebral
neurones.
Primary
generalized;
➢Tonic clonic
➢Absence
➢Infantile
spasm
➢myoclonic
Partial/focal
seizures
➢Motor
➢Sensory
➢Visual
➢Versive
➢Temporal
Recognition-
• A positive medical history for seizures.
• Typical pre seizure appearance or signs which differ in
different individuals, - aura, may be seen.
• Loss of consciousness.
• Generalized tonic – clonic seizure.
Treatment-
• Usually self limiting , convulsions lasting 2-5 minutes.
• Place patient in supine position.
• Primary aim is to prevent injury.
• Remove all materials and instruments from mouth & vicinity.
• Gently restrain patient.
• Maintain PABC on recovery .
• If convulsion last for more than 5 minutes or reappear at short
intervals, dial EMS.
• In the meantime administer diazepam 0.3 mg/kg, IV if
trained.
CONCLUSION
• Many medical emergencies can be treated without drugs.
Without ABCDs of CPR, drugs are of little value.
• All office personal should be trained to assist in the
recognition and management of emergencies, which
includes biannual renewal of BLS skills.
• The office staff should have pre-assigned specific
responsibilities so that in the event of an emergency each
person knows how to manage.
REFERENCES
• Marwah N, Nonpharmacological Behaviour Management, Textbook
of Pediatric Dentistry,3rd ed. Jaypee;2014; 219.
• Casamassimo et.al. Pain reaction control : sedation, Pediatric
Dentistry Infancy through Adolescence, 5th ed. Elsevier; 2013; 110
• Malamed SF. Emergency Medicine in Pediatric Dentistry: Preparation
and Management. C.D.A. journal. 2003; 31.
• Vranić DN et al. Medical Emergencies in Pediatric Dentistry. Acta
stomatol Croat. 2016;50(1):72-80 .
• Basic Life Support/ Cardiopulmonary Resuscitation. American
Academy Of Pediatric Dentistry, 2015.
• Management of Medical Emergencies. American Academy Of
Pediatric Dentistry , 2015 ; 37.