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MEDICAL EMERGENCIES IN COMMUNITY
Presented by: Jigyasha timsina Batch 2011
Emergency An unforeseen combination of circumstances or the
resulting state that calls for immediate action
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WHY FOCUS ON MEDICAL EMERGENCIES???
Does not allow time for orderly information gathering and formulation of a narrow differential diagnosis before the initiation of therapy.
“When you prepare for emergency, the emercency ceases to exist”
APPROACH TO A MEDICAL EMERGENCY
Comprehensive medical history Vigilant observation & prompt PREVENTION recognition of symptoms of an emergency
Basic life support PREPARATION
Affiliation to definitive medical care
Did you know ??? A person who receives BLS has 20%increase in survival rate than one who does not…so just act..
Emergency drug kit ADA suggests that following drugs
should be included as minimum in emergency kit.
1. Oxygen2. Epinephrine 1:1000(injectable)3. Nitroglycerin (sublingual tablet or
aerosol spray)4. Histamine blocker (injectable)5. Bronchodilator (asthma
inhaler - salbutamol)6. Aspirin7. Oral carbohydrate
Other drugs Glucagon
Atropine Ephedrine Corticosteroids Morphine Naloxone Nitrous oxide Injectable benzodiazepine Flumazenil
Most CommonEMERGENCIES
SYNCOPE SEIZURE
TRAUMA
ASTHMATIC ATTACK
HYPOGLYCAEMIA
AIRWAY OBSTRUCTION
ALLERGIES
CHEST PAIN DRUG TOXICITY
SYNCOPE
Defined as a short loss of consciousness and muscle strength, characterized by a fast onset, short duration, and spontaneous recovery
CAUSES
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Clinical symptoms Presyncope
Syncope
Postsyncope
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Presyncope Early
Feeling of warmth Loss of skin colour Heavy perspiration Complaints of feeling ill Nausea Hypotension Tachycardia
Late Pupillary dilatation Hyperpnea Cold hands and
feet Hypotension Bradycardia Visual disturbances Dizziness
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Syncope Breathing
Irregular, jerky and gasping Dilated pupils – death like appaerance Convulsive movements Bradycardia < 50 beats/min Weak thready pulse Loss of consciousness Partial or complete airway obstruction
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Postsyncope Pallor Nausea Weakness Sweating
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MANAGEMENT
Position: supine position with brain and heart at same level with feet elevated slightly (10 to 15 degree)
ABC – Basic life support as needed
Definitive management : Monitor vital signs Administer aromatic ammonia Administration of atropine
(0.1mg/ml)
If delayed recovery seek medical assistance
SEIZURE• A paroxysmal disorder of cerebral
function characterized by an attack involving changes in the state of consciousness ,motor activity or sensory phenomena.
• Usually sudden in onset and of brief duration.
EPILEPSY- “A chronic brain disorder of various etiologies characterized by recurrent seizures”
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Common symptoms
PREVENTIONIf pt is a 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 equipment ready in case of an emergent status epilepticus.
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Management Self limiting emergency
Position : supine with patient placed on flat surfaces
Remove dangerous objects from the mouth and around the patient eg. sharp instruments, needles, etc.
Loosen any tight clothing.
Avoid restraining the patient
In case the ictus fails to subside within a maximum of 10 minutes, declare status epilepticus and proceed with definitive care.
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Definitive treatment
Diazepam 10 mg iv (2mg/min)repeat every 10 min
Phenobarbitone (100- 200mg/min) iv
Hypoglycemia Hypoglycemia is a clinical
syndrome in which low serum (or plasma) glucose levels lead to symptoms of sympatho- adrenal activation.
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Management Glucose and sugar-containing beverages
administered orally to conscious patients for rapid effect.
Alternatively, milk, candy bars, fruit, cheese, and crackers may be adequate in mild cases
IV dextrose is indicated for severe hypoglycemia, in patients with altered consciousness and during restriction of oral intake.
An initial bolus, 20-50 mL of 50% dextrose, should be given immediately.
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Glucagon, 1 mg IM (or SC), is an effective initial therapy for severe hypoglycemia in patients unable to receive oral intake or in whom an IV access cannot be secured immediately.
TRAUMA • Trauma refers to damage, impairment or external
voilence producing injury or degeneration.
• Trauma of the oral and maxillofacial region occur frequently
• comprises 5% of all injuries for which people seek treatment.
• Among all facial injuries, dental injuries are the most common, of which crown factures and luxations occur most frequently.
• The most common location is the anterior maxilla followed by the anterior mandible.
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A traumatic injury in a maxillofacial region can result in:
- Fractures of the jaws - Fractures of the teeth - Soft tissue injuries - Injuries to vital stuctures
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Management:
Avoid patient movement before determining extent of trauma
Airway: Chin lift. Jaw thrust. Manually move the tongue forward. Maintain cervical immobilization
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Hemorrhage control
Maxillofacial bleeding:Direct pressure.
Nasal bleeding:Direct pressure.Anterior and posterior packing.
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• First aid should be given for the injuries occurred.
• The patient should be referred to the nearby higher centres for further diagnosis and care
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Chest pain
Includes commonly : Angina pectoris Myocardial infarction
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Angina PectorisAngina is defined as“a characteristic
thoracic pain, usually substernal; precipitated chiefly by exercise, emotion, or a heavy meal; relieved by vasodilator drugs and a few minutes rest; and a result of moderate inadequacy of the coronary circulation.”
Produced when myocardial blood supply cannot be sufficiently increased to meet the increased oxygen requirement that results from coronary artery disease.
Recognize the problem discontinue dental treatment
P- position patient comfortably
A,B,C –ascess airway, breathing and circulation
Definitive management
If history of angina existsAdminister vasodilator and O2 If pain resolvesConsider future dental treatment modificationMonitor vital signs
No history of anginaAdminister O2 and consider nitroglycerinMonitor and record
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Acute Myocardial Infarction Myocardial infarction is a clinical syndrome
caused by a deficient coronary arterial blood supply to a region of myocardium that results in cellular death and necrosis.
The syndrome is usually characterized by severe and prolonged substernal pain similar to but more intense and of longer duration than the angina pectoris.
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Acute myocardial infarction should be suspected if :
A first episode of chest pain suggestive of acute MI that occurs either at rest or with ordinary activity. It may develop during dental treatment especially if patient is dental phobic.
Change in previous stable pattern of pain
which may be increased in frequency or severity.
Chest pain is suggestive of MI in a patient with known CAD if relieved by rest or nitroglycerin.
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Recognize the problem(chest pain )
↓Discontinue the dental treatment
↓P—position patient comfortably
↓A→B→C—assess airway, breathing and circulation
↓D—definitive treatment
presumptive Dx :acute MI Administer O2, consider nitroglycerin Administer aspirin Manage pain(parenteral opoids) Monitor and record vital signs Prepare to manage complications(e.g. cardiac arrest) Stabilize and transfer to hospital emergency department
Management
No history of anginaAdminister O2 and consider nitroglycerinMonitor and record
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Airway Obstruction
Causes:
• Foreign body (usually food) • Infection or posttraumatic hematoma• Obstruction by the tongue • Trauma
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Presentation
• Stridor• Impaired or absent phonation• Choking and respiratory distress• Angioedema• Fever• Evidence of trauma
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Management• Is directed at rapid relief of obstruction to
prevent cardiopulmonary arrest and anoxic brain damage.
• Perform the head tilt and chin lift maneuver if cervical spine trauma is not suspected.
• Perform a jaw thrust if cervical spine trauma is suspected.
• Attempt to ventilate the patient with a bag-valve-mask apparatus.
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• Perform the Heimlich maneuver (subdiaphragmatic abdominal thrust) repeatedly until the object is expelled from the airway.
• If the situation cannot be managed, the patient should be referred to a nearby hospital or a health post.
Heimlich maneuver
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If the patient is unconscious:• Place the patient in supine position.
• Open patient’s airway by using head tilt chin lift technique.
• Place the heel of one hand against the victims abdomen in the midline slightly above the umbilicus & well below the xiphoid process.
• Place one hand on top of other hand.
• Press in to the victims abdomen with quick inward and upward thrust.
Asthma
A clinical state of hyper reactivity of the tracheobronchial tree, characterized by recurrent paroxysms of dyspnea and wheezing
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Signs and symptoms Feeling of chest tightness Dyspnea Tachypnea Cough Use of Accessory/Respiratory Muscles Agitations
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The most likely times for an acute exacerbation are:During and immediately after
local anesthetic administration.
With stimulating procedures such as extraction.
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Management Discontinue the dental procedure and allow the
patient to assume a upright position.
Establish and maintain a patent airway and administer Beta 2 agonists via inhaler or nebulizer.
Administer oxygen if possible If no improvement is observed and symptoms
are worsening, administer epinephrine subcutaneously (1:1,000 solution, 0.01 mg/kg of body weight to a maximum dose of 0.3 mg).
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Begin diligent basic life support.
Document in time form the beginning of the event.
Alert emergency medical services.
Maintain a good oxygen level until the patient stops wheezing and/or medical assistance arrives.
Escort patient to hospital as needed.
MANIFESTATIONS AND MANAGEMENT OF LOCAL ANESTHETICS OVERDOSE
50MANIFESTATIONS MANAGEMENT
MILD OVERDOSE Talkativeness, slurred speech, anxiety , confusion
Stop administration of
LA-Monitor all vital
signs-Observe for 1 hr
MODERATE TOXICITY
Slurring speech, nystagmus, tremor,headache, dizziness , blurred vision,drowsiness
-Stop administration of
LA-Place the patient in supine position
-Monitor vital signs
-Administer oxygen
-Observe in office for 1 hr
51SEVERE TOXICITY
Seizures, cardiac arrythymia or arrest
- Place the patient in supine positions - If seizures occur, protect the patient from nearby objects.- Suction the oral cavity if vomiting occurs.- Summon medical assistance.-Monitor vital signs.-Administer oxygen.-Start I.V infusion.-Administer diazepam 5-10mg slowly.-Provide basic life support.-Transport to emergency.
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Epinephrine (vasoconstrictor) overdose reactions
• Available concentrations are 1:50000, 1:100000, 1:200000.
• The optimal concentration for the prolongation of anaesthesia with lidocaine is 1:250000.
• Maximal dose: Healthy adult - 0.2 mg Cardiac patient - 0.04 mg
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Clinical manifestations:
Signs - Rise in blood pressure and heart rateSymptoms - Anxiety - Restlessness - Perspiration - Dizziness - Weakness - Pallor - Palpitation
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Management
Terminate the dental procedure Position the patient in upright position Reassure the patient Basic life support if indicated Monitor vital signs Summon medical assistance Administer oxygen
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TOXINS / DRUGS
TOXIC DOSE MANIFESTATIONS
MANAGEMENT SPECIFIC ANTIDOTES
1. Acetaminophen
>140mg/kg or at least 7.5g
AnorexiaVomitingDiaphoresis
GI decontaminationAdministration of activated charcoal
Acetylcysteine The total dose is 300 mg/kg, given as 3 separate doses
2. Anti-depressants(eg:amytryptilline, desipramine, imipramine)
20mg/kg causes few fatalities35mg/kg-approx lethal dose>50mg/kg-likely to cause death
MydriasisIleusUrinary retentionHyperpyrexia
GI decontaminationGastric lavage with activated charcoalIV sodium bicarbonate
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OPIOIDS Although opioids have been used as an
effective analgesic drug,most of the time,it has been used as an abusive product.
Opioid toxicity can result in: - Respiratory depression - Depressed level of consciousness - Miosis
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Treatment
Gastric lavage
Antidote(naloxone hydrochloride,initial dose of 2 mg IV)
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ALCOHOL
The toxicity of alcohol is dose related. Blood levels >100 mg/dL are associated
with ataxia. At 200 mg/dL, patients are drowsy and
confused. At levels >400 mg/dL, respiratory
depression is common and death is possible.
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Treatment
Administration of 100 mg thiamine IV .. Treat hypoglycaemia with 50 ml of 50%
dextrose solution
Provide oxygen therapy as needed
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GENERALISED ANAPHYLAXIS
Acutely life threatening condition. Reactions develop rapidly 5-30 minutes. Signs and symptoms of generalised anaphylaxis are
highly variable.
Four major clinical syndromes are: 1. Skin reactions 2. Smooth muscle spasm 3. Respiratory distress 4. Cardiovascular collapse
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USUAL PROGRESSION OF ANAPHYLAXIS
Skin
Eye , Nose , GI
Respiratory system
Cardiovascular system
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MANAGEMENT
• Terminate dental procedure & stop administration of all drugs presently in use.
• Position the patient comfortably.• Basic life support as indicated.• Monitor vital signs.
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Definitive Management
No CVS or respiratory involvement: - Administration of oral or IM anti-
histamine.
CVS or respiratory involvement: - Reposition the patient - Administration of epinephrine - Administration of anti-histamines
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To conclude…. The first step in management of dental
emergencies is to prevent their occurrence
With proper knowledge medical emergencies and related complication can be easily prevented
“When you prepare for emergency, the emergency ceases to exist”
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REFERENCES Medical Emergencies In The Dental Office - 5th
Edition - Stanley F. Malamed Contemporary Oral and Maxillofacial Surgery – 5th
edition- Hupp,Ellis and Tucker Internet Sources
THANK YOU