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Good Morning. Medical emergencies in the Dental Office. Presented by : Deepti Awasthi. CONTENTS. Introduction Prevention Preparation Unconsciousness - vasodepressor syncope - postural hypotension

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  1. Good Morning

  2. Medical emergencies in the Dental Office Presented by : DeeptiAwasthi

  3. CONTENTS • Introduction • Prevention • Preparation • Unconsciousness - vasodepressor syncope - postural hypotension - acute adrenal insufficiency

  4. Respiratory disease - Airway obstruction - Asthma • Altered consciousness Diabetes Mellitus : hyperglycemia hypoglycemia • Seizures • Allergy • Chest pain • Conclusion • Refernces

  5. INTRODUCTION

  6. PREVENTION • Acc. To Mc Carthy , a complete system of physical evaluation for all prospective dental patients can prevent 90% of life threatening situation. • Physical Evaluation • Medical history questionnaire • Physical examination • Dialogue history • Psychological Evaluation Medical emergencies in the dental office

  7. Physical examination consist of : • Monitoring of vital signs • visual inspection • function tests • auscultation Medical emergencies in the dental office

  8. VITAL SIGNS • The 6 vital signs are as follows : • Blood pressure • Heart rate • Respiratory rate • Temperature • Height • weight Medical emergencies in the dental office

  9. Blood pressure • Patient arm should rest at the level of the heart, relaxed, slightly flexed & supported on a firm surface. • Lower in younger

  10. Pulse • Adults – 60- 80 beats / min • Child - 80-110 beats / min • Common site : radial artery on the thumb side of wrist. • Carotid artery can also be checked at the side of the neck. • Thumb should not be used to monitor a pulse • In infants : brachial artery is preferred in the upper arm Textbook of pediatric dentistry -S G Damle

  11. Brachial artery Carotid artery

  12. Respiratory rate • Neonate - 40 breaths / min • 1 yr - 24 breaths / min • 3-5 yr - 20 breaths / min • Adult - 16- 18 breaths / min • Hyperventilation - Medical emergencies in the dental office

  13. Temperature • 36 - 37*C / 97 - 99*F • The thermometer ,sterilized & shaken down is placed under the tongue. • It should remain in the mouth for 2 mins • Fever – 99.6*F or 37*C. Textbook of pediatric dentistry -S G Damle

  14. Height & weight • Gross obesity & extreme underweight may indicate of an active pathologic process. Textbook of pediatric dentistry -S G Damle

  15. ASA physical status classification system (1962, American Society of Anesthesiologists) • ASA I : A normal healthy patient without systemic disease • ASA II : A patient with mild systemic disease • ASA III : A patient with severe systemic disease that limits activity but is not incapacitating • ASA IV : A patient with incapacitating systemic disease that is a constant threat to life. • ASA V : A moribund patient not expected to survive 24 hrs with or with out surgery. • ASA E : Emergency operation of any variety; E precedes the number, indicating the patients physical status( ASA E-III) ArathiRao

  16. Stress reduction protocol • Recognition of medical risk and anxiety • Medical consultation • Premedication • Appointment scheduling • Minimized waiting time • Psychosedationduring therapy • Adequate pain control during therapy • Duration of dental treatment • Postoperative control of pain and anxiety Medical emergencies in the dental office

  17. PREPARATION

  18. Staff training should include: • Basic life support training for all members of dental office staff • Training in the recognition and management of specific emergency situations • Office preparation should include: • Access to emergency assistance • Availability of emergency drugs and equipment

  19. Emergency Drugs and Equipments Module one -basic emergency kit (critical drugs and equipment) Module two - noncritical drugs and equipments Module three- advanced cardiac life support Module four - antidotal drugs In each module 2 categories : • Injectable drugs • Noninjectable drugs Medical emergencies in the dental office

  20. MODULE - 1 • Injectable drugs • Epinephrine – 1: 1000 • Antihistamine – 10 mg /ml • Noninjectable drugs • Oxygen –1 E- Cylinder • Vasodialator – Nitro glycerine • Bronchodilator – Albuterol • Antihypoglycemic – sugar • Antiplatelet - Aspirin • Emergency equipments • Oxygen delivery system • Suction & suction tips • Tourniquets • Syringes • Magill intubation forceps

  21. Injectable drugs • Anticonvulsant – Midazolam • Analgesic – Morphine • Vasopressor – Methoxamine • Antihypoglycemic – 50% dextrose solution • Corticosteroid – Hydrocortisone • Antihypertensive – Esmolol • Anticholinergic – Atropine • Noninjectable drugs • Respiratory stimulant – Aromatic Ammonia • Antihypertensive – Nifedipin • Emergency equipments • Device for cricothyrotomy • Artificial airways • Equipment for endotracheal intubation. MODULE - 2

  22. MODULE-3 • Epinephrine • Oxygen • Lidocaine • Atropine • Dopamine • Morphine sulphate • Verapamil

  23. Module -4 • Opioidantagonist– Naloxone, • Benzodiazepine antagonist– Flumazenil • Antiemergence delirium drug – Physostigmine • Vasodilator – Procaine

  24. UNCONSCIOUSNESS • Common faint , was the medical emergency most often reported, accounting for more than 50% of all emergency situations • Predisposing factors : 1)Stress 2)Impaired physical status 3)Administration or ingestion of drugs Medical emergencies in the dental office

  25. Possible causes of unconsciousness in dental office: • Vasodepressor syncope • Drug administration / ingestion • Orthostatic hypotension • Epilepsy • Hypoglycemic reaction • Acute adrenal insufficiency • Acute allergic reaction • Acute myocardial infarction • Hyperglycemic reaction • Hyperventilation syndrome.

  26. Prevention • Can be prevented by a thorough pretreatment medical & dental evaluation of the patient • Use of Sedation techniques • Sit-down dentistry, with patients in supine or slightly recumbent position.

  27. MANAGEMENT • 2 objectives : • A. Recognition of unconsciousness • B. Management of unconscious victim.

  28. RECOGNITION : Step 1 : Assessment of consciousness. 3 Criteria should be used : • Lack of response to sensory stimulation • Loss of protective reflexes • inability to maintain patent airway Pain is another stimulus that may be used. Step 2 :terminate dental procedure Step 3 : summoning of help

  29. MANAGEMENT • Step 4 : position victim

  30. Step 5 : assess & open airway

  31. Head tilt – chin lift Jaw thrust Pediatric basic life support

  32. Step 6 a : assess airway patency & breathing

  33. Step 6 b : Artificial ventilation • May be provided by 3 ways : • Exhaled air ventilation • Atmospheric air ventilation • Oxygen- enriched ventilation Exhaled air ventilation- 16% to 18% of inspired oxygen & maintains an oxygen saturation 97% to 100% which is adequate to maintain life. • Mouth to mouth breathing • Mouth to nose breathing Adults - 10-12 times / minute Children & infants - 20 times / minute MEDICAL EMERGENCIES IN the dental office

  34. Atmospheric air ventilation– delivers 21% of oxygen • Self inflating bag-valve-mask devices (BVM) : • Ambu bag • Pulmonary manual resuscitaton Artificial airways Oxygen enriched ventilation- Includes portable E cylinder with adjustable oxygen flow (10-15L/min) & a face mask , an E cylinder with a demand valve mask unit. Pediatric basic life support

  35. Step 7 : assess circulation monitoring heart rate & BP Carotid artery is most reliable In child, brachial artery is recommended • Step 8 : Definitive management

  36. Recovery position Pediatric basic life support

  37. If there are no signs of life • Start chest compression. • Combine rescue breathing and chest compression. • For all children, compress the lower half of the sternum: • To avoid compressing the upper abdomen, locate the xiphisternum by • finding the angle where the lowest ribs join in the middle. Compress the • sternum one finger’s breadth above this. • Compression should be sufficient to depress the sternum by at least onethird • of the depth of the chest. • Don’t be afraid to push too hard. Push “hard and fast”. • Release the pressure completely, then repeat at a rate of 100 – 120/ min • After 15 compressions, tilt the head, lift the chin, and give two effective • breaths. • Continue compressions and breaths in a ratio of 15:2. • In children – 5:1 2010 resuscitation guidelines

  38. Pediatric basic life support

  39. Automated external defibrillators • successful use of AEDs in children less than 8 years • capable of identifying arrhythmias accurately in children and are extremely unlikely to advise a shock inappropriately. • purpose-made paediatric pads or programmes- 50 -75 J 2010 resuscitation guidelines

  40. Automated external defibrillator

  41. VASODEPRESSOR syncope • Common faint A sudden, transient loss of consciousness that usually occurs secondary to a period of cerebral ischemia. Synonyms: • Atrialbradycardia • Benign faint • Neurogenic syncope • Psychogenic syncope • Simple faint • Swoon • Vasodepressor syncope • Vasovagal syncope Medical emergencies in the dental office

  42. Predisposing factors • Psychogenic : • Fright • anxiety • stress • unwelcome news • pain • sight of blood or instruments • Non –Psychogenic • standing position • hunger • missed meal • exhaustion • poor physical condition • hot, humid environment. • Male • 16-35 years Medical emergencies in the dental office

  43. Early Feeling of warmth Pallor perspiration Nausea BP at baseline Tachycardia Late Pupillary dilation Yawning Hypernoea Cold hands & feet Hypotension Bradycardia Visual disturbances Dizziness Loss of consciousness • Clinical manifestations: • Grouped into 3 definite phases : • Presyncope • Syncope • Postsyncope • Presyncope :

  44. Syncope : • Breathing may become – irregular, jerky, gasping quiet , shallow cease entirely • Pupils dilate • Convulsive movements & muscular twitching • Bradycardia (<50 beats /min) • Low BP(30/15mm Hg) • Weak & thready pulse • Fecal incontinence may occur

  45. Postsyncope: • Pallor • Nausea • weakness • sweating • Short period of confusion or disorientation. • BP and heart rate returns toward the baseline. • Pulse becomes stronger.

  46. MANAGEMENT • PRESYNCOPE : • Step 1 - position • Step 2 - A-B-C • Step 3 - D (definitive care) proceed if both doctor & patient feel otherwise treatment should be postpond Medical emergencies in the dental office

  47. SYNCOPE : • Definitive care : assess consciousness Activate office emergency system Position patient supine with feet elevated slightly A B C D – initiate definitive care administer oxygen monitor vital signs administer aromatic ammonia administer atropine if bradycardia persists Post syncopal recovery delayed recovery Postpone treatment activate emergency medical services determine precipitating factors Medical emergencies in the dental office

  48. POSTURAL HYPOTENSION • 2nd leading cause of syncope • A disorder of autonomic nervous system in which syncope occurs when the patient assumes an upright position • result of a failure of the baroreceptor -reflex -mediated increase in peripheral vascular resistance in response to positional changes Medical emergencies in the dental office

  49. Predisposing factors • Drug administration & ingestion • Prolonged periods of recumbancy • Inadequate postural reflex • Pregnancy (later stages) • Advanced age • Varicose veins • Addison’s disease • Physical exhaustion • Starvation • Chronic Postural Hypotension

  50. Clinical manifestation • Drop in blood pressure & lose consciousness when they stand or sit upright • Do not exhibit the prodromal signs & symptoms of vasodepressor syncope • Consciousness returns rapidly once patient is returned to the supine position • Dental consideration : • Slowly reposition patient upright • Stand nearby as patient stands after treatment Medical emergencies in the dental office

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