medical and dental emergency in the dental clinic

1. Medical and dental emergencies and complications in
dental practice and its management

2.  The medical and dental emergencies that are commonly
encountered in dental practice involve:
 syncope,
 airway obstruction,
 anaphylaxis,
 local anesthetic toxicity,
 Asthmatic attack,
 chest pain,
 hemorrhage,
 seizure.
 Myocardial
 infarction and cardiac arrest are extremely rare.

3. SYNCOPE
 Syncope is caused due to inadequate cerebral
perfusion.
 Causes of sudden loss of consciousness and
collapse include
 hypotension,
 adrenal crisis,
 anaphylaxis,
 cardiac arrest,
 diabetic collapse, hypoglycemia, epileptic seizure,
fainting,
 or stroke

4. THE EARLY MANIFESTATIONS
 nausea,
 warmth,
 perspiration,
 baseline blood pressure,
 and tachycardia

5. LATE MANIFESTATION
 hypotension,
 bradycardia,
 pupillarydilation,
 peripheral coldness,
 visual disturbance

6. MANAGEMENT:
 The patient should be in the supine position
 Recovery is almost instantaneous if the
patient has simply fainted.
 Then maintain airway, check pulse (if
absent,
 indicates cardiac arrest), and start CPR
immediately

7. SYNCOPE MANAGEMENT : TRENDELENBURG
POSITION

8. AIRWAY OBSTRUCTION
 Airway obstruction is usually caused due to
accidental slippage,
 aspiration of foreign objects,
 or laryngeal spasm. Patient
 manifests with :
 inability to speak, grasps the throat (universal
 sign), coughs, inability to exchange air (in spite
of respiratory movements), cyanosis, and loss
of consciousness. These might eventually lead
to cardiac arrest finally.

9. MAMAGEMENT
 Main priority is to clear the airway, but the
 method differs depending upon whether the
patient is conscious or unconscious.

10.  If the patient is conscious, then
 he/she must be made to sit straight, support
chest with one
 hand, and deliver five sharp back blows
between the shoulder blades with the heel of
the other hand. But if the patient is choking, an
attempt is made to expel the object with upward
 thrusts using Heimlich thrust [Figure 3]. It acts
as artificial cough that produces a rapid
increase in intra-thoracic pressure
 thus helping to expel the foreign body [Figure 4].

11. FIGURE 3

12. ASSESS SEVERITY FIGURE 4
Encourage cough
and observe the
patient for
ineffective cough
Sever airway
obstruction(inef
fective cough
Mild airway
obstruction
(effective cough)
Unconscious start
CPR
Conscious 5 back
blow 5 abdominal
thrust

13. ANAPHYLAXIS
 It is a hypersensitive state that results from
exposure to an allergen.
 The most common allergen in a dental setup
 is latex

14. MANIFESTATIONS
 vary from a mild form where the patient presents with
:
 erythematous rash,
 cyanosis, nausea,
 vomiting,
 tachycardia,
 utricaria,
 or angiodema
 to a severe form which leads to:
 airway obstruction or inadequate blood pressure and
blood flow to the brain which is a life-threatening
situation

15. MANASGEMENT
 involves lying the patient in the supine
position with legs raised
 , administer oxygen, and the drug of choice
being 0.5 ml of 1:1000 adrenaline IM or SC

17. MANAGEMENT OF ANAPHYLAXIS

18. LOCAL ANAESTHIA TOXICITY
 Toxicity is usually either due to the local
anesthetic itself or the vasoconstrictor which
can be due to rapid infusion or failure to
aspirate before injection

19. GENERALLY
 the reactions are self limiting. Toxicity
presents with :
 talkativeness,
 slurred speech,
 anxiety,
 confusion,
 drowsiness, or even seizure and cardiac
arrhythmias in extreme cases.

20.  monitor vital signs.
 Administer oxygen and in adverse cases
 administration of diazepam 5 mg slowly is
advised

21. ASTHMATIC ATTACKE
 Anxiety, infection, exposure to an allergen or
drugs can precipitate an asthmic attack

22.  The goal of management during an acute
asthmatic episode on a dental chair should
be to:
 relieve the bronchospasm associated with
the attack
 Hence, the patient should primarily be
relieved of irritants and all articles should be
removed from oral cavity.

23.  Drug of choice is 2 puffs of albuterol
(bronchodilator)
 . If no improvement isseen in 15 seconds
then administer 1:1000 adrenaline 0.5 ml
 SC/IM and
 if still no response is observed in 2-3 min
then
 salbutamol slow IV injection is advised.[

24. CHEST PAIN
 Factors that precipitate chest pain include:
 angina,
 acute myocardial infarction,
 gastrointestinal reflux disease,
 anxiety,
 costochondritis and paroxysma
supraventricular tachycardia

25.  Taking history from patients is very important
here

26.  Quality of pain can also indicate whether the
patient is having
 an angina or acute myocardial infarction. In
angina pectoris pain is significant but not
severe
 whereas an acute myocardial infarction pain
generally radiates to left side of the body-left
 shoulder, left mandible, left arm.[

27.  For angina pectoris, drug of choice is a nitrate,
 commonly nitroglycerine, sublingual tablet,
translingual or transmucosal spray.
 Management of a patient with suspected acute
myocardial infarction involves administration of
 morphine, oxygen, nitroglycerine, and aspirin
(MONA)
 in addition to emergency medical service. If morphine
is
 unavailable, the specialist can also substitute nitrous
oxide/oxygen in a 50:50 concentration

28. HEAMORRHAGE
 as dental specialists deal with blood routinely and
there are instances when significant bleeding could
lead into an emergency. Emergency management
begins by :
 gently cleaning the mouth and locating the source of
bleeding
 and the application of cold compress,
 pressure packs, or styptics(substance capable of
stopping bleeding when applied to a wound)
 .Suture the area under L.A when necessary.
 Tranexamic acid –500 mg in 5 ml by slow IV injection
is the drug ofchoice

29. SEIZURES
 Patients who convulse in dental office
generally have a seizure history and are
often characterized as having epilepsy

30. MANAGEMENT
 Place him in a spine position
 Remove all instrument from his mouth
 Clear airway
 Loosen the closthes

31.  If seizure continues for long, then the
condition is known as status epilepticus. This
is a life-threatening emergency and is best
managed with
 I.V. diazepam 5 mg IV/IM or
 by maintaining BLS( basic life support) till
patient is shifted to emergency medical care.

32. DM
 Elevated glucose levels in blood and urine.
Persons diagnosed with Diabetes may suffer
from too high or too low blood sugar at times
depending on medications, food intake,
illness or stress

33. SIGN AND SYMPTOMS
 Hypoglycemia: Hyperglycemia
 - Rapid onset –within minutes - Slow Onset – hours or days or weeks
 (can be fatal) - Hot, dry
 - Nervousness - Flush malaise
 - Pallor - Nausea vomiting
 - Weak, dizzy - Stupor
 - Hunger, nausea - Drowsy
 - Mental confusion - Irritability
 - Lethargy or belligerence - Headache
 - Decreased rate of breathing - Acetone odor
 - Increased heart rate - Decreased rate of
breathing
 - Decrease in blood pressure - Increased heart rate
 - Seizures - Decrease in blood
pressure
 - Tingling sensation in feet/hands
 - Loss of consciousness, coma

34.  Treatment Precautions:
 • Ensure patient has eaten and has had their
medication before the appointment
 • Keep appointments short
 • Have a sugar supplement on hand
 Treatment:
 • If conscious and able to swallow well, give
sugar supplement. Call EMS if patient doesn’t
feel better
 in 15 minutes or becomes unconscious.
 • If unconscious call EMS immediately

35. Situation Agent Regimen
Standard general
prophylaxis
Amoxicillin Adults: 2g
Children: 50mg/kg
orally
1 hour before the procedure
Inability to take oral
medications
Ampicillin Adults: 2g
Children: 50 mg/kg
IM/IV
30 min before procedure
Allergy to penicillin Clindamycin or
Cephalexin/Cefadroxil or
Azithromycin/
Clarithromycin
Adults 600 mg
Children 20 mg /kg
Adults 2g
Children 50mg/kg
Adults 500 mg
Children 50 mg/kg
Orally
1 hour before the procedure
Allergy to penicillin and
inability to take oral
medications
Clindamycin or
Cefazolin
Adults 600mg
Children 20mg/kg
IV 30 min before
Adults 1g
Children 25 mg/kg
IM/IV 30 min before

36. BASIC LIFE SUPPORT (BLS)

37. Module one – critical or essential emergency drugs
Category Generic drug alternative quantity Availability
Allergy –
anaphylaxis
Epinephrine None 1 preloaded
syringe +3x1
ml ampules
1:1000
(1mg/ml)
allergy –
histamine
blocker
Chlorphenira
mine
Diphenhydra
mine
(Benadryl)
3x1 ml
ampules
10 mg/ml
Oxygen Oxygen 1 “E” cylinder
Vasodilator Nitroglycerin Nitrostat
sublingual
tablets
1 metered spray
bottle
0.4 mg /metered
dose
Bronchodilator Albuterol Metaproterenol 1 metered dose
inhaler
Metered aerosol
inhaler
Antihypoglyce
mic
Sugar Insta – glucose
gel
1 bottle
Inhibitor of
platelet
aggregation
Asprin None 2 packets 325mg/tablet

38. Module two – secondary/ noncritical drugs and equipment
Category Generic Drug Alternative Quantity Availability
Anticonvulsant Midazolam diazepam 1x5 ml vial 5 mg/ml
Analgesic Morphine
sulphate
Meperidine 3x1 ml ampules 10 mg/ml
Vasopressor Phenylephrine 3x1 ml ampules 10 mg/ml
Antihypoglycem
ic
50% dextrose Glucagon 1 vial 50 ml ampule
Corticosteroid Hydrocortisone
sodium succinate
Dexamethasone 2x2 ml mix- o –
vial
50 mg/ml
Antihypertensive Esmolol Propranolol 2x100 mg/ml
vial
100 mg/ml
Anticholinergic Atropine Scopolamine 3x1 ml ampules 0.5 mg/ml
Respiratory
stimulant
Aromatic
ammonia
2 boxes 0.3 ml/vaporole
Antihypertensive Nifedipine 1 bottle 10mg/capsule

39. Module three – Advanced Cardiac Life Support (ACLS) : essential
drugs
Category Generic Drug Alternative Quantity Availability
Cardiac Arrest epinephrine 3x10 ml
preloaded
syringes
1:10,000
(1mg/10ml
syringe)
Analgesic Morphine
sulphate
N2O – O2 3x1 ml ampules 10 mg/ml
Antidysrhythmic Lidocaine Procainamide 1 preloaded
syringe and 2x5
ml ampules
100 mg/ syringe
Symptomatic
Bradycardia
Atropine Isoproterenol 2x10 ml
syringes
1.0 mg/10 ml
Paroxysmal
Supraventricular
Tachycardia
verapamil 2x4 ml ampules 2.5 mg/ml

40. Establishing an emergency airway –
Non invasive procedures
Invasive procedures

45. example of how to place an unconscious
patient into the lateral recovery position – always ensure that the chin is
in an elevated position to maintain airway patency

46. DENTAL COMPLECATIONS
 More than dental emergencies which require
an immediate attention and management,
the occurrence of “complications” are of
higher incidence in dental practice. The
complications may be immediate or delayed
and are related to patient’s tolerance level,
materials used and treatment procedures

47. ASPIRATION
 Aspiration may be of:
 the denture as a whole or a fractured part, a
minimal extension acrylic
 removable prosthesis,
 crowns during removal, I
 nstrument
 slippage especially broaches reamers or
files.

48.  Aspiration causes:
 airway obstruction which is manifested as the
universal sign“choking.”
 Removal of broken instruments is performed
using:
 ultrasonics, operating microscopes or
microtube delivery methods.

49. ALLERGY
 Allergy can be to latex, mercury, rubber dam,
and impression material
 Manifestations of allergy include
 pruritis,
 erythema,
 utricaria,
 and angioneurotic edema.

50.  latex-sensitive patients. Latex alternatives
(vinyl, nitrite, or silicone) and powder-free
gloves should be used to prevent
sensitization
 Fixers like formacresol and devitalizers to be
used carefully to prevent chemical burns.
 Complications involving local anaesthetics
are hypersensitivity, toxic reactions

51. MANAGEMENT
 administering prophylactic antihistamines,
such as diphenhydramine
 or corticosteroids such as prednisone before
dental treatment to those at known
 Risk
 and the drug of choice is 0.3-0.5 ml
intra-muscular or subcutaneous doses of
1:1000 epinephrine

52.  Allergic reactions can also occur to acrylic
resins, which can be minimized by:
 following proper monomer polymer ratio,
 correct curing cycle so as to minimize the
residual monomer content in the prosthesis

53. PACEMAKERS AND THE DUAL-CHAMBER ICD
 Operation of:
 the electric toothbrush,
 electrosurgical unit,
 electric pulp tester,
 high- and low-speedhandpiece, and an amalgamator did
not alter pacing function.
 the use of the ultrasonic scaler,
 ultrasonic cleaning system,
 battery-operated composite
 curing light may produce deleterious effects in patients
who
 have pacemakers or ICDs.

54. HYPOCHLORITE ACCIDENT
 wherein sodium hypochlorite is expressed
beyond the apex and patients manifests with
severe pain,
 swelling
 profuse bleeding.

55. MANAGEMENT
administration of a regional block and then
wait till maximum drainage occurs.
 Antibiotics:
 Penicillin 500 mg five times a day for 7 days
is prescribed.