ADVANCE MEDICAL ADVANCE MEDICAL EMERGENCY IN DENTISTRYEMERGENCY IN DENTISTRY

C Rini SupraptiC Rini Suprapti

KEGAWAT-DARURATAN MEDIKKEGAWAT-DARURATAN MEDIK

AKIBATAKIBAT

KOMPLIKASI ANESTESIKOMPLIKASI ANESTESI

JENIS ANESTESI DALAM BIDANGKEDOKTERAN GIGI

UMUM(NARKOSE)

LOKAL(TOPIKAL,INJEKSI)

KOMPLIKASI

ANESTESI LOKAL

ANATOMI FARMAKOLOGI

KOMPLIKASIRANGE:

TEMPORARY DISCOMFORTDEATH

Local anesthetics used in dentistry Local anesthetics used in dentistry

Complication as :Complication as :

Systemic can accur as a result of Systemic can accur as a result of psychogenic reactions induced by anxiety, psychogenic reactions induced by anxiety, toxicity secondary to high levels of the drug toxicity secondary to high levels of the drug in blood or allergyin blood or allergy

oror

LocalizedLocalized

Local mandibular block complicationsLocal mandibular block complications

VascularVascular NeuralNeural OsseousOsseous Connective tissueConnective tissue Muscular injury from needle penetrationMuscular injury from needle penetration Anesthetic deposition or localized Anesthetic deposition or localized

hemorrhagehemorrhage

Systemic complicationsSystemic complications

SyncopeSyncope Overdose reactionsOverdose reactions ToxicityToxicity HypersensitivityHypersensitivity

SERIOUS MEDICALEMERGENCY

IN THE DENTAL OFFICE

RELATIVELYRARE

MALAMED’S STUDY OF PATIENTS

HYPERVENTILATIONSEIZURE

HYPOGLYCEMIA

THE THREE MOST COMMON EMERGENCYSITUATION OCCURING IN PATIENTS

BEFORE, DURING, OR SOON AFTER GENERAL DENTAL CARE

THESE WERE FOLLOWED IN THESE WERE FOLLOWED IN FREQUENCY BY :FREQUENCY BY :

SYNCOPESYNCOPE

ANGINA PECTORISANGINA PECTORIS

HYPOTENTIONHYPOTENTION

HYPERSENSITIVITY / ALLERGIC HYPERSENSITIVITY / ALLERGIC

REACTIONREACTION

PREVENTIONPREVENTION

PREPARATION :PREPARATION :

CONTINUING EDUCATIONCONTINUING EDUCATION

OFFICE STAFF TRAININGOFFICE STAFF TRAINING

ACCESS TO HELPACCESS TO HELP

EMERGENCY SUPPLIES AND EMERGENCY SUPPLIES AND

EQUIPMENTEQUIPMENT

PREPARATION FOR MEDICAL EMERGENCIES :PREPARATION FOR MEDICAL EMERGENCIES :

1.1. PERSONAL CONTINUING EDUCATION IN PERSONAL CONTINUING EDUCATION IN EMERGENCY RECOGNITION AND EMERGENCY RECOGNITION AND MANAGEMENTMANAGEMENT

2. STAFF EDUCATION IN EMERGENCY 2. STAFF EDUCATION IN EMERGENCY RECOGNITION AND MANAGEMENTRECOGNITION AND MANAGEMENT

3.3. ESTABLISHMENT AND PERIODIC TESTING OF A ESTABLISHMENT AND PERIODIC TESTING OF A SYSTEM TO READILY ACCESS MEDICAL SYSTEM TO READILY ACCESS MEDICAL ASSISTANCE WHEN AN EMERGENCY OCCURESASSISTANCE WHEN AN EMERGENCY OCCURES

4.4. EQUIPPING OFFICE WITH SUPPLIES EQUIPPING OFFICE WITH SUPPLIES NECESSARY FOR EMERGENCY CARENECESSARY FOR EMERGENCY CARE

MISJUDGING THE ANATOMYMISJUDGING THE ANATOMY

CAN RESULT : INADEQUATE OR CAN RESULT : INADEQUATE OR

INCOMPLETE ANESTHESIAINCOMPLETE ANESTHESIA

NERVE TRAUMANERVE TRAUMA

VASCULAR INJURYVASCULAR INJURY

INTRAVASCULAR, INTRAVASCULAR, INTRAGLANDULAR, INTRAMUSCULAR INTRAGLANDULAR, INTRAMUSCULAR INJECTIONINJECTION

MIDDLE EAR PROBLEMSMIDDLE EAR PROBLEMS

EYE PROBLEMEYE PROBLEM

PERSIAPAN PERSIAPAN RIWAYAT KESEHATAN LENGKAPRIWAYAT KESEHATAN LENGKAP TD, NADITD, NADI PASIEN DALAM KEADAAN RELAXPASIEN DALAM KEADAAN RELAX POSISI PASIEN POSISI PASIEN GUNAKAN DISPOSABLE NEEDLE GUNAKAN DISPOSABLE NEEDLE LAKUKAN PENYUNTIKAN PERLAHAN TANPA LAKUKAN PENYUNTIKAN PERLAHAN TANPA

SAKITSAKIT MINIMUM DOSIS ANESTESIMINIMUM DOSIS ANESTESI LAKUKAN ASPIRASILAKUKAN ASPIRASI OBSERVASI SELAMA DAN SETELAH OBSERVASI SELAMA DAN SETELAH

PENYUNTIKANPENYUNTIKAN

Klasifikasi ASAKlasifikasi ASA

Various local reactions and Various local reactions and complicationscomplications

Local swelling and painLocal swelling and pain TrismusTrismus Infections and tissue necrosisInfections and tissue necrosis Muscular complicationsMuscular complications focal hematomafocal hematoma thromboembolic phenomenathromboembolic phenomena reflex vascular spasmreflex vascular spasm abnormal distributions of anestheticabnormal distributions of anesthetic

Adverse neurologic complications Adverse neurologic complications affecting local and distant neurologic affecting local and distant neurologic tracts have been reported following tracts have been reported following

inferior alveolar nerve injectionsinferior alveolar nerve injections Complications :Complications : cranial nerve paralysiscranial nerve paralysis anesthesia of cranial nerve II-VIIanesthesia of cranial nerve II-VII

Symptoms :Symptoms : ptosisptosis diplopiadiplopia myosismyosis facial hemiparesisfacial hemiparesis lingual anesthesialingual anesthesiaInferior alveolar nerve injectionsInferior alveolar nerve injections complete and prolonged chorda complete and prolonged chorda tympani ageusia or dysgeusiatympani ageusia or dysgeusia

Permanent nerve injury following the Permanent nerve injury following the injection of local anesthetic during dental injection of local anesthetic during dental procedures is rareprocedures is rare

Dental procedure --Dental procedure -- inferior alveolar local inferior alveolar local anesthetic injections ---- > complication--anesthetic injections ---- > complication--

injury chorda tympani nerveinjury chorda tympani nerve

HypogeusiaHypogeusia

AgeusiaAgeusia

DysgeusiaDysgeusia

Chorda tympani nerveChorda tympani nerve

a branch of cranial nerve VIIa branch of cranial nerve VII

afferent fiber (suply sensory innervation to afferent fiber (suply sensory innervation to taste receptors in the anterior two-thirds taste receptors in the anterior two-thirds of the tongue) of the tongue) Sensory information is transmitted to the Sensory information is transmitted to the medulla and on to the cortical taste regions of medulla and on to the cortical taste regions of the brainthe brain and efferent fibers (preganglionic and efferent fibers (preganglionic parasympathetic fibers to the submandibular parasympathetic fibers to the submandibular and sublingual salivary glands) and sublingual salivary glands)

Schiffman and HenkinSchiffman and Henkin Taste disordersTaste disorders Testing of sense of taste by Testing of sense of taste by electrogustometryelectrogustometry chemical gustometrychemical gustometry !!!! Mandibular or inferior alveolar nerve block !!!! Mandibular or inferior alveolar nerve block

anesthesianesthesiHarn : 2.075 patients >>> 3.62% chance of Harn : 2.075 patients >>> 3.62% chance of

traumatizing the lingual nerve with a traumatizing the lingual nerve with a conventional mandibular blockconventional mandibular block

Seddon’s original nerve injury classificationsSeddon’s original nerve injury classifications (1943) is still often quoted in the medical and (1943) is still often quoted in the medical and

dental literaturedental literature Neuropraxia : a transient nerve dysfunction Neuropraxia : a transient nerve dysfunction

without significant degeneration and without without significant degeneration and without disruption of axonal integrity.disruption of axonal integrity.

(recovery days-weeks)(recovery days-weeks) Axontemesis : a traumatic neural injury with Axontemesis : a traumatic neural injury with

resultant distal degeneration of nerve axons but resultant distal degeneration of nerve axons but without disruption of the endoneurium. without disruption of the endoneurium.

(recovery about 6-8 weeks)(recovery about 6-8 weeks) Neurotemesis ( a traumatic neuronal injury with Neurotemesis ( a traumatic neuronal injury with

physical disruption and distortion of the nerve physical disruption and distortion of the nerve structure )structure )

KOMPLIKASI --- ANATOMIKOMPLIKASI --- ANATOMI

Secara umum ada 4 type :Secara umum ada 4 type : 1. Injuri pada jaringan syaraf1. Injuri pada jaringan syaraf 2. Injuri pada pembuluh darah2. Injuri pada pembuluh darah 3. Trauma pada otot3. Trauma pada otot 4. Reaksi sistemik4. Reaksi sistemik

Regio kepala dan leher :Regio kepala dan leher :

Ditambah dengan intra glandular yang dapat Ditambah dengan intra glandular yang dapat menimbulkan sekuelemenimbulkan sekuele

Nerve injuryNerve injury Paresthesia ( loss of sensation )Paresthesia ( loss of sensation )

tongue tongue

lower liplower lip

weeks or monthsweeks or months Hyperesthesia (increased sensitivity to Hyperesthesia (increased sensitivity to

painful stimuli)painful stimuli) Dysesthesia (pain following noxious stimuli)Dysesthesia (pain following noxious stimuli)

Proses pasif :Proses pasif : Difusi obat anestesi ke daerah orbita Difusi obat anestesi ke daerah orbita

mengakibatkan gejala ekstra okular mengakibatkan gejala ekstra okular termasuk kelumpuhan otot otot ekstra okular termasuk kelumpuhan otot otot ekstra okular seperti diplopia ( penglihatan ganda ) atau seperti diplopia ( penglihatan ganda ) atau bahkan dapat terjadi kebutaan temporer.bahkan dapat terjadi kebutaan temporer.

Horner’s syndrome seperti enophtalmos, Horner’s syndrome seperti enophtalmos, miosis (pupil konstriksi) dan palpebral ptosis miosis (pupil konstriksi) dan palpebral ptosis ( droping of the eyelid )( droping of the eyelid )

Kadang kadang terjadi temporary loss atau Kadang kadang terjadi temporary loss atau blurring of vision unilateralblurring of vision unilateral

BleedingBleeding

Highly vascular area >>> risk >>> Highly vascular area >>> risk >>> intravascular injection, vascular damage, intravascular injection, vascular damage, hemorrhage with hematoma formationhemorrhage with hematoma formation

Vein : bleeding minimalVein : bleeding minimal Artery : rapid bleeding with significant Artery : rapid bleeding with significant

hematoma formationhematoma formationObservation at 24-48 hour intervals for any Observation at 24-48 hour intervals for any

signs of recurrent bleeding or secondary signs of recurrent bleeding or secondary infection of the hematomainfection of the hematoma

Systemic complicationsSystemic complications

Intra venaIntra vena

local anesthesi sol.local anesthesi sol.

Intra arterial injectionIntra arterial injection

Capable of producing systemic toxicity

Patient exitabilityElevated heart rateSeizure progressing

Loss of consciousness

MANIFESTASI DAN MANAGEMEN MANIFESTASI DAN MANAGEMEN REAKSI ALERGIREAKSI ALERGI

SKIN SIGNSSKIN SIGNS

DELAYED ONSETDELAYED ONSET : : ERYTHEMA, URTICARIA,PRURITUS.ERYTHEMA, URTICARIA,PRURITUS.

STOP DRUGSTOP DRUG

REFER TO PHYSICIANREFER TO PHYSICIAN

IMMEDIATE ONSET SKIN SIGNS :ERYTH. URT., PRUR.IMMEDIATE ONSET SKIN SIGNS :ERYTH. URT., PRUR.

STOP DRUGSTOP DRUG

EPINEPRINE 0.3 ML 1:1000 SC,IM/IVEPINEPRINE 0.3 ML 1:1000 SC,IM/IV

ANTIHISTAMIN BENADRYL 50 MG IM/IVANTIHISTAMIN BENADRYL 50 MG IM/IV

MONITOR VITAL SIGNMONITOR VITAL SIGN

REFERREFER

OBSERVATION 1 HROBSERVATION 1 HR

LANJUTANLANJUTAN

RESPIRATORY TRACT SIGNSRESPIRATORY TRACT SIGNS WITH OR WITHOUTWITH OR WITHOUT CARDIOVASCULAR OR SKIN SIGNS CARDIOVASCULAR OR SKIN SIGNS

WHEEZING, MILD DYSPNEAWHEEZING, MILD DYSPNEA

STOP DRUGSTOP DRUG SITTING POSITIONSITTING POSITION EPINEPRINEEPINEPRINE REFER REFER MONITORMONITOR

-MODERATE TO SEVERE DYSPNEA :-MODERATE TO SEVERE DYSPNEA : STOP DRUGSTOP DRUG SITTING POSITIONSITTING POSITION EPINEPRINEEPINEPRINE OXYGENOXYGEN VITAL SIGNVITAL SIGN IV ACCESS IF SIGNS IV ACCESS IF SIGNS

WORSEN TREAT AS WORSEN TREAT AS ANAPHYLAXIS ANAPHYLAXIS REFER REFER

ANAPHYLAXIS :ANAPHYLAXIS : MALAISE, WHEEZING,MOD-SEV DYSPNEA, MALAISE, WHEEZING,MOD-SEV DYSPNEA,

CYANOSIS, TOTAL AIRWAY OBSTR., NAUSEA AND CYANOSIS, TOTAL AIRWAY OBSTR., NAUSEA AND VOMITING, ABDOMINAL CRAMPS, URINARY VOMITING, ABDOMINAL CRAMPS, URINARY INCONTINENCE, TACHYCARDIA, HYPOTENSION, INCONTINENCE, TACHYCARDIA, HYPOTENSION, CARDIAC DYSRHYTMIAS, CARDIAC ARRESTCARDIAC DYSRHYTMIAS, CARDIAC ARREST

STOP DRUGSTOP DRUG SUPINE POSITIONSUPINE POSITION EPINEPRINEEPINEPRINE BLSBLS VITAL SIGNVITAL SIGN CONSIDER CRICOTHYROTOMYCONSIDER CRICOTHYROTOMY IV ACCESSIV ACCESS OXYGEN 6 L/MINOXYGEN 6 L/MIN ANTIHISTAMIN IV/IMANTIHISTAMIN IV/IM PREPARE TO TRANSPORTPREPARE TO TRANSPORT

KESIMPULANKESIMPULANKUNCI UTAMA : KUNCI UTAMA :

PAHAMIPAHAMI

ANATOMIANATOMI

FARMAKOLOGI OBAT OBAT ANESTESIFARMAKOLOGI OBAT OBAT ANESTESI

PERSIAPAN PADA PASIENPERSIAPAN PADA PASIEN

PERSIAPAN ALAT ALAT PERSIAPAN ALAT ALAT

OBAT OBATAN UNTUK MENGATASI OBAT OBATAN UNTUK MENGATASI KEADAAN DARURATKEADAAN DARURAT

SEGERA RUJUK PASIEN KE RS SEGERA RUJUK PASIEN KE RS TERDEKAT BILA BLS TIDAK MEMBANTUTERDEKAT BILA BLS TIDAK MEMBANTU

BILA BLS TIDAK MEMBANTU ????BILA BLS TIDAK MEMBANTU ????

ALSALS

SEGERA RUJUK PASIEN KE RS SEGERA RUJUK PASIEN KE RS

TERDEKAT TERDEKAT

TERIMA KASIHTERIMA KASIH