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Unconsiousness
- 1. UNCONSIOUSNESS IN DENTAL CLINIC AND ITS MANAGMENT Dr. Wael M. Talaat Assistant Professor of Oral and Maxillofacial Surgery
- 2. Objectives 1. 2. 3. 4. Diagnose Unconsciousness Know possible causes Be familiar with BLS Management
- 3. DEFINITION UNCONSCIOUSNESS : lack of response to sensory stimulation. Most common emergency situation reported in dental clinic is UNCONSCIOUSNESS
- 4. POSSIBLE CAUSES 1.Vasodepressor syncope 2.Drug Administration or ingestion 3.Orthostatic hypotension 4.Epilepsy 5.Hypoglycemic reaction
- 5. RARE CAUSES Acute adrenal insufficency Acute allergic reaction Acute myocardial infarction Cerebrovascular accident Hyperglycaemic reaction Hyperventilation
- 6. PATHOPHYSIOLOGY 1.INADEQUATE DELIVERY OF OXYGEN TO BRAIN OXYGEN BRAIN ACTIVITY UNCONSCIOUSNESS
- 7. CLINICAL EXAMPLE : 1. Hypotension 2. Acute Adrenal insufficency 3.Vasodepressor Syncope 4. Orthostatic Hypotension
- 8. 2.Systemic or local metabolic deficiencies Chemical or metabolic derangments Changes in Quality of blood reaching the brain
- 9. CLINICAL EXAMPLE Acute allergic Reaction Drug Ingestion And administration
- 10. 3- Direct or reflex effect on nervous system Due to defect in brain itself
- 11. CLINICAL EXAMPLE : Cerebrovascular accidents Convulsive Episodes
- 12. 4.Psychic Mechanisms Emotional disturbances are most common cause of transient loss of consciousness in dental clinic
- 14. MANAGEMENT IMMEDIATE MANAGEMENT OF UNCONSIOUSNESS IS PRE-DICTATED ON TWO OBJECTIVES. 1.RECOGNITION OF UNCONSIOUSNESS 2.RECOGNITION OF POSSIBLE AIRWAY OBSTRUCTION AND MANAGMENT
- 16. STEP ONE :ASSESSMENT OF CONSIOUSNESS LACK OF RESPONSE TO SENSORY STIMULUS TO CHECK WHETHER VICTIM LACK A RESPONSE TO SENSORY STIMULATION.
- 17. GENTLY SHAKE VICTIMS SHOULDER AND SHOUT LOUDLY ‘ARE U ALL RIGHT’
- 18. Pain IS ANOTHER STIMULUS APPLICATION OF PERIPHERAL PAIN PINCHING EVOKES A MOTOR RESPONSE
- 19. STEP 2 TERMINATION OF DENTAL PROCEDURE
- 20. STEP 3 SUMMONING OF HELP IF NO RESPONSE TO PERIPHERAL STIMULATION Rescuer calls for assistance immediately by activating the dental office emergency system
- 21. 2.RECOGNITION OF POSSIBLE AIRWAY OBSTRUCTION AND MANAGMENT
- 22. STEP 4 P – POSITION VICTIM SUPINE POSITION WITH BRAIN AT THE SAME LEVEL AS HEART AND FEET ELEVATED SLIGHTLY
- 23. OBJECTIVES SUPINE POSITION INCREASED DELIVERY OF OXYGENATED BLOOD TO BRAIN O2 HEART BRAIN ELEVATED FEET Increase return of blood to heart OTHER BODY PARTS HEART Oxygenated blood
- 24. IN PREGNANT PATIENTS TURN TO LEFT SIDE And tuck a pillow on right side because the inferior vena cava, which carries the blood from the lower body is on the right side and so if she is on the left it will not be compressed
- 25. STEP 5 A – Assess and open airway Opening of airway and restoration of breathing are most basic and important steps of BLS
- 26. HEAD TILT CHIN LIFT APPLYING DOWNWARD PRESSURE ON HEAD BY USING PALM APPLYING UPWARD PRESSURE ON MANDIBLE USING FINGERS
- 28. JAW THRUST RESCUERS FINGERS ARE PLACED BEHIND POSTERIOR BORDER OF MANDIBLE DISPLACES MANDIBLE FORWARD ,DISLOCATING WHILE TILTING HEAD BACKWARD
- 29. Response to jaw thrust maneuver tells the rescuer how deeply unconscious that victim is
- 30. A movement or audible sound is considered positive
- 31. STEP 6a :assess airway patency and (B) Breathing Assess the patency of breathing LOOK LISTEN AND FEEL TECHNIQUE At chest movements Feel and hear air at victims nose
- 32. NO RESPONSE ADDITIONAL MANAGEMENT 1. administration of oxygen 2. monitoring of vital signs HEART RATE – BP – RESPIRATORY RATE
- 33. STEP 6b:Artifical Ventilation VICTIM MAY RECEIVE ARTIFICAL VENTILATION IN ONE OF THE THREE WAYS 1.EXHALED AIR VENTILATION 2.ATMOSPHERIC AIR VENTILATION 3.O2 enriched Ventilation
- 35. 2.ATMOSPHERIC AIR VENTILATION DEVICES TO DELIVER ATMOSPHERIC OXYGEN TO LUNGS AMBU BAG AND PULMONARY RESUSCICATOR
- 36. Ventilation Bag-Mask Ventilation 1 Person difficult, less effective 2 Persons easier, more effective
- 37. AIRWAY ADJUNCTS AIRWAY ADJUNCTS USED DEEPLY UNCONSCIOUS INDIVIDUALS
- 38. Open the Airway Oropharyngeal Airway
- 39. Open the Airway Nasopharyngeal Airway
- 40. Open the Airway Endotracheal Intubation
- 41. Open the Airway Laryngeal Mask Airway (LMA)
- 42. 3.O2 enriched Ventilation E cylinder– 10 TO 15L for 30 minutes of oxygen It consists of 1.Portable E Cylinder 2.FACE mask CAPACITY A <B <C < D Type cylinder are also available
- 43. STEP 7 C - Circulation Monitoring heart rate and blood pressure Sites FOR Monitoring Heart rate 1.Brachial and Radial Arteries in Arm 2.Carotid Artery in Neck
- 44. IF pulse not palpable within first 10 seconds
- 46. 2 mechanisms explaining the restoration of circulation by external cardiac massage Cardiac pump Thoracic pump
- 47. Cardiac pump during the cardiac massage Blood pumping is assured by the compression of heart between sternum and spine STERNUM HEART SPINE Between compressions thoracic cage is expanding and heart is filled with blood THORACIC CAGE BLOOD HEART
- 48. Thoracic pump at the cardiac massage During the chest compression blood is directed from the pulmonary circulation to the systemic circulation. pulmonary circulation systemic circulation. blood
- 49. STEP 8 DEFENITIVE MANAGMENT Which is specific for each condition
- 50. SUMMARY RECOGNIZE THE PROBLEM P - POSITION A–B–C D – DEFENITIVE CARE
- 51. Thank You
- 53. VASODEPRESSOR SYNCOPE Most common cause Young fit adult males are more prone
- 54. Presyncope • Stress increased release of Catecholamines • peripheral vascular resistance peripheral pooling of blood
- 55. blood to heart low BP decresed cerebral blood flow compensatory mechanism
- 56. compensatory mechanism BARORECEPTOR REFLEXES CONSTRICT PERIPHERAL BLOOD VESSELS CAROTID & AORTIC REFLEX HEART RATE
- 57. compensatory mechanism FATIGUED REFLEX BRADYCARDIA Heart rate less than 50 times per minute UNCONSIOUSNESS CARDIAC OUTPUT
- 58. Signs & symptoms 1. 2. 3. 4. 5. 6. 7. Early Feeling of warmth Loss of colour :pale or ashen gray skin tone Heavy perspiration Complaints of feeling “bad” or “faint” Nausea Blood pressure at baseline Tachycardia
- 59. Late 1. Dilated pupils Hypotension Dizziness, weakness or nausea Visual disturbances Cold moist skin Bradycardia 2. 3. 4. 5. 6.
- 60. Management of syncope ASSESS CONSIOUSNESS Activate office emergency team P – Position patient supine with feet elevated
- 61. Provide definitive management of unconsciousness Administer oxygen Monitor vital signs
- 62. Perform additional procedures Aromatic ammonia Atropine, if bradycardia persists delayed recovery POST PONE DENTAL TREATMENT Activate EMS
- 64. It is a disorder of the autonomic nervous system in which syncope occurs when the patient assumes an upright position Fall in systolic pressure by 20mm of Hg or greater or a 10mm Hg or greater fall in diastolic pressure that occurs on standing Failure of baroreceptor reflex mechanism POSITION VARIATION decrease constriction of peripheral blood vcssels return of blood to heart
- 65. Management of postural hypotension Assess level of consciousness Activate office emergency team Position patient supine with feet elevated Assess & open airway
- 66. Assess airway patency &breathing Assess circulation Administer oxygen Monitor vital signs
- 67. If patient recovers consciousnessslowly reposition the chair & discharge the patient
- 68. Delayed recovery – summon medical assistance- continue BLS as needed & discharge the patient
- 69. 3.SEIZURES
- 70. Definition :A sudden change in behavior due to excessive electrical activity OF the brain Symptoms of seizures differ depending on what part of the brain is affected.
- 73. RECOGNIZE PROBLEM (lack of response to sensory stimulation) DISCONTINUE DENTAL TREATMENT ACTIVATE OFFICE EMERGENCY TEAM
- 74. P-position patient in supine position with feet elevated Seizure ceases Allow patient to recover before discharge
- 75. IF SEIZURE CONTINUES (>5 min) A B C Perform BLS as Needed
- 78. PRODORMAL PHASE Recognize aura Discontinue dental treatment Activate office emergency team C-D UNUSUAL FEELINGS P- A –B-
- 79. IF SEIZURE PERSISTS FOR MORE THAN 5 MINUTES A-B-C-D if AVAILABLE administer IV ANTICONVULSANT
- 80. Drug administration or ingestion
- 81. Drug administration or ingestion Clinical signs and symptoms that result from overly high blood levels of a drug in various target organs and tissues Drug overdose reactions or toxic reactions Direct extension of normal pharmacologic actions of the involved drug.
- 82. Clinical manifestations of local anesthetic overdose SIGNS Low to moderate overdose levels 1. Confusion 2. Talkativeness 3. Apprehension 4. Excitedness 5. Slurred speech 6. Generalized stutter 7. Muscular twitching and tremor of the face
- 84. 9.Elevated blood pressure 10. Elevated heart rate 11.Elevated respiratory rate
- 85. Moderate to high blood levels 1.Generalized tonic-clonic seizure,followed by 2.Generalized central nervous system depression 3.Depressed blood pressure,heart rate & respiratory rate
- 86. Management of a severe LA overdose with slow or rapid onset ASSESS CONSIOUSNESS Activate office emergency team P – Position patient supine with feet elevated
- 87. Administer oxygen Monitor vital signs
- 88. administer IV ANTICONVULSANT Activate EMS Medical consultation
- 90. Also known as Stroke Defined as any vascular injury that reduces cerebral blood flow to a specific region of the brain , causing neurologic impairment It is a focal neurologic disorder caused by destruction of brain substance as a result of intra-cerebral hemorrhage , thrombosis, embolism or vascular insufficiency.
- 93. Diagnostic clues Hypertension (blood pressure above 140/90mm Hg) Altered consciousness Hemiparalysis Headache and blurred vision Asymmetry of face and pupils of eyes
- 94. ASSESS CONSIOUSNESS Activate office emergency team P – A –B - C
- 95. Administer oxygen Monitor vital signs
- 96. ESTABLISH IV ACCESS ( 5 % DEXTROSE) TRANSPORT TO EMERGENCY MEDICAL CARE
- 97. Hyperglycemia
- 98. Elevated blood glucose level Patients blood glucose level remain elevated for prolonged period due to lack of insulin BLOOD Glucose Insulin
- 99. SYMPTOMS
- 100. MANAGMENT Step 1:Termination of dental therapy Step 1a:Activation of dental office emergency Step 2: 2:Unconscious patients should be placed into the supine position with their legs elevated slightly
- 101. supine position
- 102. Step 3:Removal of dental materials from mouth Step 4:A-B-C(basic life support)as needed.
- 103. DEFINITIVE CARE Step 5 :D(definitive care) Step 5a:summoning of medical assistance Step 5b:IV infusion(if available)of 5%dextrose and water or of normal saline
- 104. Dextrose
- 105. Step 5c:Administration of oxygen . Step 5d:Transportation of the patient to the hospital DentalClinic Hospital
- 106. Hypoglycaemia
- 107. Most dangerous complication of diabetes since the brain is starved of glucose Diagnosis Deepening drowsiness Disorientation Excitability or aggressiveness in a diabetic patient, especially if it is known that a meal has been missed
- 108. SYMPTOMS
- 109. Management of hypoglycaemia Position the patient supine with legs elevated. Assess Airway Breathing Circulation. Administer BLS as needed.
- 110. 4 lumps of sugar Give 150 ml glucose drink Reassure patient
- 111. give sterile glucose IV (20ml of 20-50% of solution)or IM glucagon 1mg Call an ambulance Where possible, defer further immediate dental treatment until another day. If unconscious,
- 112. Management of sudden loss of consciousness in the absence of an obvious diagnosis STEP 1 :Lay the patient flat . Recovery is almost instantaneous if the patient has simply fainted . Call for assistance
- 113. STEP 2:Maintain the airway &give oxygen
- 114. STEP 3:Take the pulseif absent CPR is immediately indicated.
- 115. STEP 4 : If pulse is palpable give 4sugar lumps orally if the patient has not completely lost consciousness or 20ml of 20-50%sterile glucose IV if unconscious. GLUCOSE
- 116. STEP 5: Still no improvement –medical assistance should be summoned. Give hydrocortisone sodium succinate 200mgIV Defer further immediate dental treatment until another day.
- 117. CONCLUSION UNCONSCIUOSNESS IS THE MOST COMMON EMERGENCY CONDITION REPORTED IN DENTAL CLINIC SO, as a Dentist we all should know how to manage unconsciousness condition in the dental clinic