1.
EMERGENCIES IN DENTAL PRACTICE

2.
Introduction:
 Medical emergencies occurring in the dental clinic are
uncommon but may be life threatening.

3.
 They are anticipated and prevented by:
i. Careful history taking and assessment of
the patient.
ii. Adequate training in the management of
medical emergencies.
iii. Readily accessible emergency kit that is
regularly checked and reviewed.

4.
Emergencies
1. Sudden loss of consciousness
2. Acute chest pain
3. Difficulty in breathing
4. Convulsions

5.
 Sudden loss of consciousness:
1. Fainting
2. Anaphylactic reaction.
3. Acute hypoglycemia.
4. Myocardial infarction
5. Cardiac arrest
6. Adrenal crisis
7. Thyroid crisis.
Emergencies that may arise during dental
procedures include:

6.
 Acute chest pain:
1. Angina
2. Myocardial infarction
 Difficulty in breathing:
1. Asthma
2. Anaphylactic reaction
3. Foreign body aspiration

7.
 Convulsions:
1. Epilepsy
2. Fainting (minor convulsions may be associated).

8.
BASIC LIFE SUPPORT(BLS)
 ABC’s
 A-airway
 B-breathing
 C-circulation
 D-decompression
 E-exposure

9.
Airway (A)
 If an obstruction is present ,clear the airway
,remove foreign bodies ,debris or blood with
aspirator
 Open the airway ,head tilt ,chin lift & tongue
thrust
 Give O2 at a high inspired conc. up to 1 L/min
 Use a pulse ox meter if available ,aim for a
normal O2 saturation (97-100%)

10.
Open Airway
Upper airway obstruction
by the tongue & epiglottis
“Head tilt-
chin lift”
“Jaw thrust”
If suspected
head trauma

11.
Breathing (B)
 Look, listen & feel for signs of respiratory
distress
 Count the respiratory rate (normally12-20
b/min)assess the depth of breathing
 If depth & rate of breathing is inadequate
consider mask ventilation with supplemental
O2

12.
Circulation (C)
 Look at the color of the hands &face
 Assess the limb temp i.e., is the hand cool or
warm
 Measure the capillary refill time by pressing on
finger tip held at the level of the heart with
enough pressure to cause blanching and see
how long the skin takes to revert to the color
of the surrounding skin (should be less than 2
sec)
 Count the pt’s pulse rate

13.
Basic life support guidelines
Make sure the
patient and you
are safe.
Check the patient
for response
Shout for help
Maintain the
airway by tilting
the pt.’s head and
lifting the chin
Look, listen and
feel for normal
breathing
Call ambulance
15 chest
compressions
2 rescue breaths

14.
Disability (D)
 To help exclude common causes of
uncounsciousness
 Review & ttt the ABCs ,exclude hypoxia & decreased
B.P
 Check the pt’s drug record for reversible drug-induced
causes of depressed consciousness
 Make a rapid initial assessment of the ptns conscious
level using AVPU method:
 Alert
 Responds to local stimuli
 Responds to painful stimuli
 Unresponsive to all stimuli
 Measure the blood glucose to exclude hypoglycemia
,using a glucose meter if available

15.
Exposure (E)
 To assess & treat the pt properly ,loosening or
removal of some of the pt clothes may be
necessary ,such as around the neck &chest

16.
Fainting
 Most common cause of sudden loss of
consciousness in the dental surgery.
 Signs and symptoms:
 Dizziness, weakness or nausea
 Pale, cold moist skin
 Initially slow and weak pulse, becoming
rapid.
 Loss of consciousness
 Minor convulsions and incontinence are
occasionally associated

17.
Vasovagal syncope
 The most common cause of transient loss of
consciousness
 Triggered by emotional stress, anxiety, sudden
or unexpected pain, the sight of blood or
needles
 Is characterized by the dramatic interruption of
compensatory response, with a simultaneous
decrease in blood pressure and heart rate,
mediated by a reduction in sympathetic tone
and an increase in vagal tone

18.
Vasovagal syncope
 Pathophysiology & manifestations of vasovagal syncope
Anxiety
Increased heart rate ,feeling of warmth ,pallor ,rapid
breathing & breathlessness caused by
compensatory
mechanism
Decompensation
Reflux vagally mediated bradycardia ,nausea
,weakness ,hypotension
Reduced cerebral blood flow
Lightheadness ,syncope
If prolonged ,seizure activity

19.
Management of a fainting attack
a) Reassure the patient.
b) Position pt in supine posture with legs raised
above level of head
c) Cool towel to forehead
d) Loosen any tight clothing round the neck
e) Give a sweetened drink when consciousness has
been recovered.
f) Recovery is usually rapid
 If no recovery within a few minutes consider other
causes of loss of consciousness.

20.
a) Monitor vital signs
b) Check for breathing
If absent If present
.Start BLS .crush ammonia ampule
.Call medical assistant under nose
.Consider other causes of .administer O2 &
monitor
Syncope ,including hypoglycemia vital signs
,cerebral vascular accident , .have ptn
escorted home
Cardiac dysrhythmia .plane anxiety
reduction protocol
on future visits

21.
Diabetic collapse:
hypoglycemia
 Occur after an overdose of insulin or if prevented
from eating at the expected time by dental
treatment.
 Clinical features:
 Altered behavior, such as aggression, irritability,
and confusion.
 Sweaty, tachycardia, pale, and drowsy.
 Fits, confusion, disorientation
 Loss of consciousness will develop rapidly
 Signs of hypoglycemia may be similar to those of
faint, but with little response to laying the patient
flat.

22.
Treatment
1. Stop dental treatment.
2. If conscious:
 give a glucose drink (20 g of glucose) quickly.
3. If unconscious:
1) Give 20 ml of 50% glucose IV
2) Give 20 ml of 20% glucose IV, or
3) Give 1 mg of glucagon IM

23.
Anaphylaxis
 It is an acute type 1 hypersensitivity reaction.
 Clinical feature:
I. Cutaneous:
Erythema
Urticaria
Angioedema
Facial flushing

24.
I. Respiratory system:
I. Tongue and upper airway swelling
II. Breathlessness
II. Cardiovascular system
I. Hypotension
II. Rapid & weak pulse
III. Central nervous system
I. Loss of consciousness

25.
Treatment
1. Stop dental treatment and reassure the
patient.
2. Give oxygen by face mask.
3. Allow the patient to adopt the most
comfortable position for them because
patient’s position during anaphylaxis is
guided by their symptoms.
1. If feeling faint, the patients must lay
flat
2. If they are short of breath, sitting
upright with oxygen is less distressing.

26.
 If hypotension, airway edema or bronchospasm present,
give the following in order:
1. Adrenaline (epinephrine) 0.5ml of 1:1000 IM
 Adrenaline is the life saving drug during
anaphylaxis
 Take 10-30 min to act
 Should not be given intravenously
 May need to be repeated after 10 minutes if
no response
 Chlorpheniramine 10-20 mg IV or IM
 An antihistamine
 Less potent and slower acting than the
adrenaline

27.
 Hydrocortisone 100- 500 mg IV or IM every 6
h up to 4 times
 Takes up to 6 hours to act
 Prevent late relapse
 Reassure the pt
 Call an ambulance an hospitalize the pt
 Defer dental ttt until another day

28.
Asthma
 Acute exacerbation of asthma can be precipitated
by pain or stress associated with dental treatment.
 Clinical features:
 Breathlessness
 Expiratory wheezing
 Inability to talk
 Rapid pulse( greater than 110 beats/min)
 Life threatening features of a severe asthmatic attack:
 Cyanosis
 Slow heart rate (less than 50 beats/minutes)
 Hypotension
 Confusion

29.
Treatment
a) Stop the dental treatment and reassure the patient.
b) Allow the patient to sit upright
c) Give oxygen
d) Give normally used anti-asthmatic drugs
(salbutamol inhaler)
e) Give hydrocortisone sodium succinate 200 mg IV
f) If no response within 2-3 min., give salbutamol or
terbutaline by slow IV (if these drugs are
unavailable or the pt. condition deteriorate, give
adrenaline 0.5 mg solution IM).
g) Call for medical help and transfer the pt to the
hospital.

30.
Angina
 Angina Pectoris is the name given to paroxysms of severe
chest pain
 These are caused by higher myocardial Oxygen demands
 The underlying cause is coronary atherosclerotic plaques that
rupture
 Obstruction of the arterial supply to the myocardium
 The basic disease process is progressive narrowing &/or
spasm of one or more of the coronary arteries
 Reversible ischemia.
 Clinical features:
 classically described as sense of heaviness, tightness, or
compression of the chest that radiates down the left arm. It may
radiate to the neck or the jaw. The patient tends to grip his hand over
his chest and may sit forward.
 sweaty, short of breath and tachycardia.

31.
Treatment
a) Stop dental treatment
b) Reassure the patient
c) Sit the patient up
d) Give oxygen
e) Give glyceryl trinitrate (GTN) 0.5 mg sublingual tablets
( repeat GTN dose until the patient improves)
f) If angina pain does not respond to GTN and oxygen
represents developing MI
g) Pain that persists after 3 doses of nitroglycerin given
every 5 min; that lasts more than 15 min; or that is
associated with nausea, vomiting, or hypertension is
highly suggestive o MI
h) Conscious sedation and GA should be deferred for 3
months in pts with recent angina, unstable angina or
recent development of bundle branch block

32.
Myocardial infarction (MI)
 Irreversible ischemia.
 Between 30-50% of pts die within the first hour
and a further 10-20 % within the next few days
 Clinical features:
 chest pain is more severe
 Pain is prolonged and not relieved by rest or GTN.
 Associated with pronounced sweating,
breathlessness (due to heart failure), rapid pulse and
vomiting.
 cardiac arrest may occur at anytime.
 Death is often from ventricular fibrillation or cardiac
arrest

33.
Treatment (MONA)
a) Stop the dental treatment.
b) Sit the patient up.
c) Reassure the patient.
d) Morphine 10 mg iv. Alternatively, nitrous oxide with
at least 30% oxygen to relieve pain and anxiety
e) Give oxygen.
f) Give GTN 0.3 mg
g) Give aspirin 300 mg po to chew.
h) Be ready for a possible cardiac arrest requiring
CPR.
i) Transfer the patient to the hospital

34.
Cardiac Arrest
 Sudden and complete loss of cardiac function.
 Clinical feature:
 Unconscious with a death like appearance (not
responsive).
No breathing.
 No pulse.
 Irreversible brain damage occurs within 3 min. if
adequate circulation is not established.

35.
Can be due to
 Ventricular fibrillation accounts for most cardiac
arrests
 Myocardial infarction
 Hypoxia
 Drug overdose
 Anaphylaxis
 Severe hypotension
 Anesthetic overdose

36.
Management
• Assess the situation, shake the pt and ask in a
loud voice ‘Are you OK’
• If there is no response
• Call for medical help
• Lay the pt on the floor
• Basic life support (BLS) and cardiopulmonary
resuscitation (CPR) is needed to maintain
adequate ventilation and circulation until the
emergency team arrive.

37.
Adrenal crisis
 May occur in patient with Addison's disease or
those with history of corticosteroid therapy.
 Triggered by GA, trauma, stress, or infections
 Prevented by;
 Careful medical history
 Adequate steroid cover must be give.
 Clinically:
 Pallor
 Tachycardia
 Sweating
 Rapidly falling blood pressure (hypotension)
 Weakness and confusion
 Loss of consciousness and sometimes hypoglycemia.

38.
Treatment
a) Lay the patient flat and raise the legs.
b) Give oxygen
c) Give at least 200 mg hydrocortisone sodium
succinate IV
d) Monitor the airway and pulse
e) Call for medical help
f) Take blood for glucose & electrolyte estimation
 IV infusion of 1 liter of dextrose saline may be
required.
 Steroid supplementation should be continued for at
least 3 days after the blood pressure has returned to
normal

39.
Thyroid Crisis
 A rare life threatening condition that may occur
in patient with hyperthyroidism.
 Clinical features:
 Anxiety
Tremor
 Dyspnea
 May lead to ventricular fibrillation, coma and death.

40.
Treatment
a) Stop dental treatment and summon for help.
b) Give antithyroid drugs;
 Propanolol 5 mg / 6 hour IV
 Carbimazole 20 mg/8 hours PO
 Potassium iodide
 Propylthiouracil
c) Medical assistance

41.
Epileptic Fits
 Uncontrolled neuronal electrical activity within the
brain.
 Clinical features:
 some patients may have a brief warning cry. Patient
may look vacant, distant or withdrawn
 consciousness lost immediately
 Fit starts with a tonic phase of muscle contraction. The
body becomes rigid and cyanosis appears.
 This is followed by the clonic phase characterized by
widespread jerking movements
 Sometimes incontinence or frothing of the mouth
 After a fit the patient slowly recovers consciousness
and is disoriented.

42.
Treatment
a) Stop dental treatment and remove all instruments
from the mouth
b) Place the patient on the floor and prevent injury
from adjacent equipment
c) Most fits terminate spontaneously.
d) Don’t give any medication and await recovery
e) Reassure the patient as soon as consciousness
returns
f) If convulsions do not stop within 5 min/ or if another
attack starts then call EMS and give the patient 10-
20 mg diazepam IV:
i. If venous access can’t be obtained give midazolam 5
mg IM
ii. Repeat the diazepam or midazolam if no recovery
within 5 min. transfer the patient to the hospital.

43.
Essential drugs recommended for emergency
use in dentistry
Drug Formulation Route
Oxygen Oxygen cylinder Inhalational
Adrenaline 0.5 ml of 1 :1000
solution
IM or SC
Hydrocortisone sodium
succinate
100 mg powder
2ml sterile water
IM or IV
Chlorpheniramine 10 mg in 1 ml solution IV or IM
Glucagon 1 mg powder
1 ml sterile water
IM
Salbutamol inhaler 0.1 mg/dose Inhalational
Glyceryl trinitrate 0.5 mg tablets
0.4 mg/ dose spray
Sublingual
Aspirin 300 mg tablets PO
Midazolam 10 mg in 2ml solution IM