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Emergency in dental practice.pptx

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Emergency in dental practice.pptx

  2. 2. Introduction:  Medical emergencies occurring in the dental clinic are uncommon but may be life threatening.
  3. 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. 4. Emergencies 1. Sudden loss of consciousness 2. Acute chest pain 3. Difficulty in breathing 4. Convulsions
  5. 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. 6.  Acute chest pain: 1. Angina 2. Myocardial infarction  Difficulty in breathing: 1. Asthma 2. Anaphylactic reaction 3. Foreign body aspiration
  7. 7.  Convulsions: 1. Epilepsy 2. Fainting (minor convulsions may be associated).
  8. 8. BASIC LIFE SUPPORT(BLS)  ABC’s  A-airway  B-breathing  C-circulation  D-decompression  E-exposure
  9. 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. 10. Open Airway Upper airway obstruction by the tongue & epiglottis “Head tilt- chin lift” “Jaw thrust” If suspected head trauma
  11. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 23. Anaphylaxis  It is an acute type 1 hypersensitivity reaction.  Clinical feature: I. Cutaneous: Erythema Urticaria Angioedema Facial flushing
  24. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 35. Can be due to  Ventricular fibrillation accounts for most cardiac arrests  Myocardial infarction  Hypoxia  Drug overdose  Anaphylaxis  Severe hypotension  Anesthetic overdose
  36. 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. 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. 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. 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. 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. 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. 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. 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