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ภาวะฉุกเฉินทางการแพทย์ (Medical Emergencies) ในคลินิกทันตกรรม PowerPoint Presentation
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ภาวะฉุกเฉินทางการแพทย์ (Medical Emergencies) ในคลินิกทันตกรรม

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ภาวะฉุกเฉินทางการแพทย์ (Medical Emergencies) ในคลินิกทันตกรรม - PowerPoint PPT Presentation

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ภาวะฉุกเฉินทางการแพทย์ (Medical Emergencies) ในคลินิกทันตกรรม. การป้องกัน (Prevention) การจัดการ (Management). Patient at Risk Dentist at Risk. Introduction. Emergencies in dental practice can occur to any person, any time.

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ภาวะฉุกเฉินทางการแพทย์ (Medical Emergencies) ในคลินิกทันตกรรม

  • การป้องกัน (Prevention)
  • การจัดการ (Management)

Patient at Risk

Dentist at Risk



  • Emergencies in dental practice can occur to any person, any time.
  • How to manage, it is the most difficult thing at time occurred.
allergic reaction

angina pectoris

postural hypotension


asthmatic attack



anaphylactic reaction

cerebrovascular accident

adrenal insufficiency

thyroid storm






Composition of consciousness

  • Brain
  • O2
  • Glucose
  • Effective hemodynamic
fact of human brain
Fact … of human brain
  • Uses O2 approx. 20% of total O2
  • Uses glucose approx. 65% of total glucose
  • Uses approx. 20% of total circulation/min (750 ml.min.)


Balance mechanism of :

  • Hemodynamic
  • Respiration
  • Metabolism
  • Neurologic


Caused from impair ……..

  • Hemodynamic
  • Respiration
  • Metabolism
  • Neurologic
how to avoid these complications
How to avoid these complications?
  • Prevention is the best
  • Good history taking
  • Good preoperative preparation
  • Good operative controls
possible causes of unconsciousness in the dental office
Vasodepressor syncope

Drug administration /ingestion

Orthostatic hypotension


Hypoglycemic reaction

Acute adrenal insufficiency

Acute allergic reaction

Acute myocardial infarction

Cerebrovascular accident

Hyperglycemic reaction

Hyperventilation syndrome

Possible causes of unconsciousness in the dental office
alteration of consciousness
Alteration of consciousness
  • Cerebrovascular accident (CVA)
  • Seizures
  • Hypoglycemia / Hyperglycemia
  • Adrenal insufficiency
  • Thyroid storm
  • Hyperventilation
  • Drug overdose


Syncope is the most common occurred.

factors influence
Factors influence
  • Stress and anxiety
  • Health status
  • Drugs
how syncope occur
How syncope occur?

In normal : circulation compensation mechanism play role in correction of deficiency O2 supply to the brain.

how syncope occur1
How syncope occur?

In syncope : circulation compensation mechanism fail to increase O2 need from the brain

signs for syncope
Signs for syncope

Early :

Feeling of warmth

Loss of color : pale or ashen=gray skin tone

Heavy perspiration

Complaints of feeling “bad” of “faint”


Blood pressure approximately baseline

Rapid heart rate

signs for syncope1
Signs for syncope

Late :

  • Pupillary dilation
  • Yawning
  • Hyperpnea
  • Cold hands and feet
  • Hypotension
  • Bradycardia
  • Dizziness
  • Loss of consciousness
critical consideration
Critical consideration
  • Timing of detection and correction
  • Maintain O2 level to the brain : Airway, Breathing, Circulation (ABC - Basic life support)
orthostatic hypotension
Orthostatic hypotension
  • Failure of the baroreceptor reflex
  • Loss of compensate mechanism
  • Reflex bradycardia
  • Loss of consciousness

Assessment : Check for Breathing

  • Look the chest to rise and fall
  • Listen for air escaping during exhalation
  • Feel for the flow of air

Unconsciousness : no response to stimuli

P - position : SUPINE

Call for help : EMS activation

A, B = Airway (head tilt - chin lift) Artificial Assisted Breathing (if no self respiration)


C = check circulation

Carotid pulse absent

Carotid pulse present

Check medical history Vital signs

Activate EMS



Initiate CPR Immediate transportation

Orthostatic hypotension

Vasodepressor syncope

sequence of bcls
Sequence of BCLS
  • Assessment
  • EMS Activation
  • ABCs of CPR
  • D of Defibrillation
abcs of cpr
  • Airway
  • Breathing
  • Circulation
  • Position the victim
  • Rescuer position
  • Open the Airway
    • Head Tilt - Chin Lift Maneuver
    • Jaw Thrust Maneuver
    • Recommendations for Opening the Airway
classification of causes of unconsciousness by mechanism

Inadequate delivery of blood or oxygen to the brain

Clinical example

Acute adrenal insufficiency

Orthostatic hypotension

Vasodepressor syncope

Classification of causes of unconsciousness by mechanism
classification of causes of unconsciousness by mechanism1

Systemic or local metabolic deficiencies

Clinical example

Acute allergic reaction

Drug ingestion and adminstration

Nitrites and nitrates



Local anesthetics




Classification of causes of unconsciousness by mechanism
classification of causes of unconsciousness by mechanism2

Direct or reflex effects on nervous system

Psychic mechanisms

Clinical example

Cerebrovascular accident

Convulsive episodes

Emotional disturbances


Vasodepressor syncope

Classification of causes of unconsciousness by mechanism
causes of chest pain
Cardiac related

Angina pectoris

Myocardial infarction

Non-cardiac related

Muscle strain



Hiatal hernia

Pulmonary embolism

Dissecting aortic aneurysm

Acute indigestion

Intestinal “gas”

Causes of chest pain
chest pain is one of the major clinical clues to the presence of significant heart disease
Chest pain is one of the major clinical clues to the presence of significant heart disease.
definition of terms
Definition of Terms

“Atherosclerosis” is a special type of thickening and hardening of medium - sized and large arteries because of deposits of a fatty substance.

  • is an ongoing process
  • is a reactive biologic response of arteries to the forces being generated by the flow of blood.
development of atherosclerosis
Development of atherosclerosis

Proliferative change

the development of acs
The development of ACS

Early plaque formation

Significant plaque formation

Plaque rupture



Coronary artery disease is the presence of atherosclerosis in the coronary arteries.

  • Angina pectoris
  • Myocardial infarction

Angina is a transient discomfort (usually less than 15 minutes) due to a temporary lack of adequate blood supply to the heart muscle.


Myocardialinfarction is defined as death of heart muscle (myocardium) as the result of prolonged inadequate blood flow and oxygen delivery.


Acute coronary syndromes encompasses symptomatic condition resulting in an inadequate blood supply to the heart; including unstable angina and AMI.


AMI (heart attack) is defined as death of heart tissue due to blockage of a coronary artery caused by atherosclerosis and thrombus formation.

unstable angina
Unstable angina
  • Angina that is continuing, prolonged or occurring at rest.
  • Represents a syndrome that lies between angina pectoris and AMI.


Angina pectoris --------------> AMI


risk factors heart attack
Risk factors : Heart attack
  • Risk factors that cannot be changed





risk factors that can be changed
Cigarette smoking

High blood pressure

High blood cholesterol level

Physical inactivity



Excessive stress

Risk factors that can be changed

Electrocardiogram (EKG)

Exercise stress test


Coronary angiography


1. Coronary artery bypass graft surgery (CABGS)

2. Medical therapy

3. Percutaneous Transluminal Coronary Angioplasty (PTCA) หรือ Percutaneous Coronary Intervention (PCI)

drugs and bleeding in patient with cad
Drugs and bleeding in patient with CAD
  • Aspirin
  • Plavix
  • Ticlid
  • Coumadin
angina pectoris
Angina pectoris
  • Potential problem related to dental care

1. Stress and anxiety related to dental visit may precipitate angina attack

2. Myocardial infarction

3. Sudden death

angina pectoris1
Angina pectoris
  • Prevention of complication

1. Detection of patient

2. Referral of patient for medical evaluation and treatment

Prevention of complication

3. Known case with medical treatment for angina

    • Stress reduction protocol
      • Premedication
      • Open and honest communication
      • Morning appointments
      • Short appointments
      • Nitrous oxide - oxygen
    • Avoid excessive amounts of epinephrine

Emergency action plan for a person with signals of heart attack

Unknown case of CAD

Recognize the signals of a heart attack

Stop activity and sit or lie down

Wait about 5 minutes to see if the symptom go away. If the pain persists :

Known case of CAD

Recognize the signals of heart attack

Stop activity and sit or lie down

Take 1 nitroglycerin tablet at a time at 3 - to 5 minutes intervals to maximum total dose of 3 tablets. If pain persists.

Transport patient to hospital

potential problem related to dental care
Potential problem related to dental care

1. Cardiac arrest

2. Myocardial infarction

3. Angina pectoris

4. Congestive heart failure

5. Bleeding tendency secondary to anticoagulant

prevention of complication
Prevention of complication

1. No routine dental care until at least 6 months after infarction

2. Medical consultation

  • Current status
  • Medication used
3. Stress reduction protocol
  • Premedication
  • Open and honest communication
  • Morning appointment
  • Short appointment
  • Nitrous oxide - oxygen

4. Avoid excessive amounts of epinephrine

5. Check PT (Anticoagulant medication)

management of acute myocardial infarction
Management of Acute Myocardial Infarction

Step 1. Diagnosis

Administer nitroglycerin

2. Initiate BLS

3. Summon medical assistance

4. Administer oxygen and monitor vital signs

5. Relive pain


Nitrous oxide - oxygen

6. Transport patient to hospital


Case Study

ผู้ป่วยชายอายุ 68 ปี มาด้วยมีส่วนแหลมคมของฟันกรามบนซ้าย เป็นฟันที่รับการรักษาคลองรากฟันและมีตัวฟันแตกออก วางแผนการรักษาโดยการถอนฟัน จากการซักประวัติ ผู้ป่วยเป็นโรคหลอดเลือดหัวใจ ได้รับการรักษาโดยการทำบอลลูน และรับประทานยาอยู่เป็นประจำ

medical problem list
1. Coronary artery disease : double - vessel

Status : post PCI พ.ค. + มี.ค. 46

at present : asymptomatic

2. DM : controlled

3. HT : controlled

4. Old CVA : Left hemiparesis 5 yrs ago at present : complete recovery

5. Mild renal insufficiency

6. Mild late onset asthma

Medical Problem List
current medication
Current medication

1. Aspent gr. V 1 x 1 orally pc.

2. Plavix 1 x 1 orally pc.

3. Plendil 1 x 2 orally pc.

4. Minidiab 1 x 1 orally pc.

5. Bestatin 1 x 1 orally pc.

6. Singvalac 1 x 1 hs.