CPR Forth Year

1. UNCONSCIOUSNESS
rd
3 Lec. 18 Mar. 2009
Dr. Adel I. Abdelhady
BDS, MsC, (Tanta, Egypt.), PhD (Egypt, USA)
Oral and maxillofacial Surgery Dept.
College of Dentistry, King Faisal university, KSA

3. UNCONSCIOUSNESS
GENERAL CONSIDERATION
General Causes of unconsciousness
Predesposing factors in dental settings
General Prevention:
Clinical manifestation:
Management of unconsciousness
VASODEPRESSOR SYNCOPE
Postural hypotension
ACUTE ADRENAL INSUFFICIENCY
Differential diagnosis

4. GENERAL CONSIDERATION
Definition

Consciousness….awareness of surroundings…
respond to questions & commands
 Unconsciousness is a lack of response to
sensory stimulation

ie Unconscious patient is a patient :
incapable of responding to
sensory stimuli with loss of the protective
mechanisms especially which maintain patent
airway
 Syncope……….sudden…transient loss of consc
 coma …prolonged loss of consc,,,as.deep sleep…..
can not be aroused by simple measurements.


5. GENERAL CONSIDERATIONS




Terms
Confusion
intermingling of ideas
Delirium illusions,
delusions
Dizziness
a
disturbed sense of
relationship to space
unsteadiness-








Causes
drug
overdose…..alcohol……
local anesthesia, sedat…
Hyperventilation
Hypoglycemia
Hyperglycemia
Hypothyroidism
Hyperthyroidism
cerebr vasc

6. Predisposing Factors





These factors includes:
1-Stress ( Vasodepressor syncope)
2- Impaired physical status( ASA III or IV)
3- Administration or ingestion of drugs( LA,
analgesics, antianxiety agents, CNS depressant
leading to alterations in consciousness
When a patient with impaired physical status is
exposed to undue physiologic or psychological
stress, the chance are even greater that this
patient may react adversely to the situation.

7.  Individuals with underlying cardiovascular
disease may respond to the stress with
sudden death secondary to cardiac
 dysrhythmias, which are precipitated by
the same physiologic stress that can
cause vasodepressor syncope in healthy
individual

9. ASA I
Healthy, normal patient
Physiologically able to tolerate the stress
Without psychological problems
No treatment modifications are indicated

10. ASA II
Mild systemic disease
Can perform normal activity without
experiencing distress
Healthy patient with more extreme anxiety
May need modification in treatment

11. ASA III
Severe systemic disease
Limited activity but not incapacitated
Need stress reduction method during dental
treatment
May need to alter treatment

12. ASA IV
Has an incapacitating disease that is life
threatening
Patient is in distress at rest
No elective dental therapy
Emergency treatment should be in hospital
setting

13. ASA V
Moribund patient - not expected to live 24
hours with or without operation

15. Prevention
 Loss of consciousness can be prevented
in many, if not most, by thorough
pretreatment medical and dental
evaluation.
 Recognition
 Termination
 Activate ER team
 Position
 A, B, C, D.

16. General Causes of unconsciousness :

1-Neurogenic & Psychogenic :

e.g. stress, injections in dental
office

vasodepressor ----> syncope..

2-Vascular

3-Cardiogenic

4-Failed Oxygenation

5-Drugs

6-Endocrine

17. Predesposing factors for uncon in
dental settings:
 1.
Stress:
 2.
Impaired physical status.
 3.
Drug : as 



analgesics
anti anxiety
antibiotics

18.  Clinical manifestation:
-
Unconscious patient is:

incapable of responding to
sensory stimuli.

- with Loss of protective
mechanisms especially which maintain
patent airway.

19. General Prevention
 1.
Preliminary patient evaluation to
recognize fearful patients and if there is
dental fear—use sedation technique.
 2. Sit down dentistry:

i.e, treat patient while lies in a supine
or slightly recumbent position.

21. Pathophysiology:



the most important factor in pathogeneses of
unconsciousness is Hypotension.
O2 deprivation: is a major pathophysiologic
factor in unconsciousness
ie Air way obstruction -->



permanent brain damage in 4 – 5 mint.
& cardiac arrest in 5-10 mint.
General , local metabolic & C.N.S. changes
also occur .

22. NB
 Psychic mechanisms: are the most
important mechanism involved in
transient loss of consciousness or
syncope


25. Inadequate Cerebral Circulation
The most common mechanism of syncope is sudden decrease in
the delivery of blood to the brain:
 1-Dilation of peripheral arterioles
 2-Failure of normal peripheral vasoconstrictor activity
( orthostatic hypotension)
 3-A sharp drop in COP heart diseases
 4-Constriction of cerebral vessels as carbon dioxide is lost in
hyperventilation
 5-Occlusion or narrowing of internal carotid or other arteries to the
brain
 6-Life-threatening ventricular dysrhythmias
 The first four cause no harm if the patient is in supine position


26. Recognition of Unconsciousness
 Step1: Assessment of consciousness :
 *Lack of response to sensory stimulation
 *Loss of protective reflexes
 *Inability to maintain a patent airway
 Step2:Terminate dental procedure.
 Step3: Summoning of help, rescuer
should call for assistance immediately by
activating the dental office emergency
system

27.  Step4: Position victim
 Strp5: Start BLS A,B,C,D
Supine posit
feet elevated 10-15

34. Causes of Partial Airway Obstruction
Sound
Probable cause
Management
Snoring
Hypopharyngeal
obstruction by the
tongue
Repeat head tilt,
jaw thrust
Gurgling
Foreign bodies (blood,
vomits) in airway
Suction airway
Wheezing
Bronchial
obstruction
Asthma
Laryngospasm
Administer
Bronchodilator
Crowing
Suction airway;
positive-pressure

38. Determination of Airway Patency and Breathing
Clinical Signs
Diagnosis
Can feel and hear air
at nose and mouth and
see chest and
abdominal movement
Can feel and hear air
at nose and mouth but
no chest and
abdominal movement
Cannot feel or hear air
at mouth and nose and
chest and abdominal
movements heaving
and erratic
Cannot feel or hear air
at mouth and nose and
no chest and
abdominal movements
Airway patent ;
patient breathing
Management
Maintain airway
Airway patent ;
patient breathing
Maintain airway
Patient attempting to
breath, but airway
obstruction still present
Repeat head tilt, if
necessary use jaw
thrust technique
Respiratory
arrest
Artificial
ventilation

40.  The basic steps in
the management of
unconsciousness are: R.t.p.- A B C D:

-R: recognition of case

-t : terminate dental
procedure
-p: position,
 - A: air way,
 - B: breathing,
 - C: circulation

43. Management of unconsciousness
R-recognition of unconsciousness

ie :assessment of consciousness :
You should diagnose unconsciousness by
A- no response to sensory stimulation : eg.
are you all right ?
response to painful stimuli
or B- no protective reflexes
or C- inability to maintain a patent airway.

T







:Terminate dental procedure .
:summoning [call] of help .

44. 



P: position care :
Supine position
feet elevated 10-15
remove any head supports

45. Supine posit
feet elevated 10-15

46. Remove
any head
supports

47.  A : airway open



By – head tilt technique
---- jaw thrust technique
---- head tilt- chin lift technique

48. Head tilt
technique

49. Jaw thrust
technique

50. Head tilt- Chin lift technique

51. Old :head tilt- neck lift technique

53. Head tilt- chin lift technique will elevate the tongue &
ensure patent air way

54. 
B : Breathing Care

*** do – look-listen & feel technique
*** if the rescuer thinks a foreign material in
the airway
he should tilt the patient back






turn the head to one side
remove any thing in oral Cavity by
fingers
or by high volume suction technique
*** then Give O2 by artificial ventilation

55. look-listen & feel technique
LLF

56. Remove any Thing in Oral Cavity by
Fingers

57.  Methods of Artificial Ventilation





Exhaled air ventilation
mouth to mouth
mouth to mask
atmospheric air ventilation
O2 enriched ventilation

58. Exhaled Air Ventilation

59. Atmospheric air ventilation

60. O2 enriched ventilation

61. C: Circulation Care
 C: circulation care
monitor heart rate

blood pressure
 If pulse is absent-> Activate CPR
external chest compression


62. Asses circulation feel carotid
pulse

63.  D: definitive


management :
depending on cause
see Causes of unconsciousness

64. VASODEPRESSOR SYNCOPE
 synonyms
:
 VASOVAGAL SYNCOPE, FAINT

Neurogenic syncope

Psychogenic syncope

Atrial bradycardia
 Definition
 sudden transient loss of consciousness
caused by reversible disturbance in
cerebral function

65.  Commonest emergency in dental off
 Relatively harmless
 PREDISPOSING FACTORS
psychogenic factors: fright ,anxiety,
 non psychogenic factors: erect ,hunger


66. CLINICAL MANIFESTATIONS OF
SYNCOPE
 -usually develops rapidly
 -passes in 3 phases:



pre syncope
syncope
post syncope

67. postsyncope
Pre
Syn
cope
syncope

68. Presyncope
 Patient is erect & complains of bad feeling
 Pallor
 Sweating
 Nausea
 Blood pre ---baseline
 Pulse ----- rapid
 Followed by
hypotension & bradycardia

69. Syncope











CNS-------loss of consc
convulsion
Death like appearance
sweating
vomiting,
Blood pr decreased
Pulse is slow [bradycardia] &low [thready]
Breathing ---irregular
Pupil -----dilates….dilates……dilates
MS--------twitches, convulsions
NB syncope lasts less than 15 m if longer ….

70. Post-syncope
 Usually recovery is rapid
 Patient ------- weakness




pallor
sweating,
nausea,
weakness,

73. ALTERED CONSCIOUSNESS
Confusion intermingling
of ideas
Delirium illusions
,delusions
Dizziness
a disturbed
sense of relationship to
space
unsteady-------

75. Predisposing factors
 Drugs
alcohol; local anesth sed,
 Hyperventilation
 Diabetes mellitus
 Thyroid gland dysfunctions

76. Prevention
 Early recognition
 Avoid drugs
medical history
 clinical exam


77. Clinical manifestation
Depend on cause
 in Hyperventilation: rapid respir rate
 in Hypoglycemia : cold wet skin
 in Hyperglycemia : hot dry skin

 in Hypothyroidism: weakness fatigue
 in Hyperthyroidism : restlessness
 in cerebr
vasc acc: sudden loss of consc

78. Management
 1-Recognize
 2- terminate dental procedure
 3-P-----depend on cause



supine position is accepitable…….
in diabetic & thyroid dis--- upright
in cerebrovasc acc---- can upright to dec bl
pr
 3- A,B,C
 4-definitive care

m- monitor vital signs

m- manage signs & symptom

d-defin tt depend on cause

79.  Important Causes of unconsciousness :

1-Neurogenic [ Psychogenic VASODEPRESSOR SYNCOPE :

2-Vascular : postural hypotension

3-Cardiogenic

4-Failed Oxygenation

5-Drugs
6-Endocrine :ACUTE ADRENAL INSUFFICIENCY


81. Prevention
 1-avoid the predisposing factors:
 2-Proper position: supine posit……
Never treat in upright posit
 3-relief anxiety : by sedations


82. Management
 Pre syncope : R T
 Syncope
P…. A B C D
: R T P…. A B C D
 Post syncope : R
T P…. A B C D

84. Postural hypotension
 The Second common cause
of uncon in
dentistry
 Definition :
a disorder of autonomic nerv syst in
which syncope occurs when the patient
assumes an upright position
or a drop of systolic bl pr ---20 mg or
more on standing

86.  CAUSE :
failure of baroreceptor reflex
 PREDISPOSING FACTORS
 prolonged recumbence
 Inadequate postural reflexes
 Drugs
 Pregnancy
 aging

87. Management of Postural hypotension
 Step 1
:R : assessment of
consciousness :
 Step 2 : T : terminate dent mang &
activate office emergency.
 Step 3 :P: position :
 Supine posit, feet elevated 10-15
 Step 4 : A : airway care

: B : breathing care

: C : circulation care

88.  Step 5 :D: definitive care :position care
 Monitor bl
,HR
 Give O2
 Step
6 :subsequent management
 changes of position must be slow

89. Adrenal dysfunctions
 Less seen in dentistry
 Hormones------ Structure------- Dys function


Hypo function-Addison dis, ,,
acute adr ins
Hyperfunction--Cushing syndr,,,
adr crisis

90. ACUTE ADRENAL INSUFFICIENCY
causes

Lack of glucocorticoids as in
 1- adrenal diseases

[ primary adrenal insufficiency ]

hage,

trauma,

infections

sudden stop of gluc c.after prol ttt
 2- pituitary diseases [secondary adrenal
insufficiency


91. Clinical Manifestations
 Weakness & fatigue
 Anorexia
& decrease weight
 hypotension
 hyper pigmentation

93. Hyper pigmentation

94. Management of ACUTE ADRENAL
INSUFFICIENCY






General Dental considerations :
consult a physician
give glucocorticoids
before
during
after stress
????????????????????

95. Manag :A- consc patient











1-R
2-T- terminate dental procedure
3-P
4- A
B
C
7-definitive care
m- monitor vital signs
m- medical assistance
o- emergency O
d-drugs glucocorticoids

96. Drugs : corticocorticoids

97. Manag :B- unconsc patient












1-R…. recognize unconsc
2-T ….
3-P…..
4- A
B
C
7-definitive care
m- no time for monitor vital signs
m- no time medical assistance
o- emergency O
d-drugs glucocorticoids
e-emergency fluid therapy

98. Differential diagnosis
 Causes of unconsc
VASODEPRESSOR SYNCOPE
Postural hypotension
ACUTE ADRENAL
INSUFFICIENCY

99.  CLINICAL ITEMS HELP TO ESTABLISH
THE CAUSE OF UNCONSCIOUSNESS
 AGE
 0—14 H E

hypoglycemia

epilepsy
 14—40 : S H E

Syncope psychogenic

hypoglycemia

epilepsy

100.  40---




H
heart diseases :
infarction,
valvular les,
cerebrovasc acc.

101. Diff diag of UNCONSCIOUSNESS

102.  STRESS……….S H E
psychogenic syncope

hypoglycemia

epilepsy

myocardial infarction,

cerebrovasc acc.
 STRESS is absent in

Postural hypotension

Drugs

Allergic reactions

Hyperglycemia


104.  Skin :pale & cold -------syncope
 Headache ---------cereb vas acc
 Chest pain------------- angina pect
 Breath
odour--------alcohol
 Heart rate incr in hypoglyce,,hyperglyc

decr in vasodepressor
 Blood pr ………

incr in cereb vas acc

107. Weakness &
fatigue
Anorexia & dec
weight
hypotension
hyper
pigmentation