ภาวะฉุกเฉินทางการ แพทย์ (medical emergencies) ใน...
TRANSCRIPT
ภาวะฉุ�กเฉุนทางการ แพทย์� (Medical
Emergencies) ในคลินกท�นตกรรม
• การป้�องก�น(Prevention)• การจั�ดการ(Management)
• Emergencies in dental practice can occur to any person, any time.
• How to manage, it is the most difficult thing at time occurred.
• The majority emergency is syncope.
– allergic reaction– angina pectoris– postural
hypotension– seizures– asthmatic attack– hyperventilation– hypoglycemia
• anaphylactic reaction• cerebrovascular
accident• adrenal insufficiency• thyroid storm• etc
Others
Composition of consciousness– Brain– O2
– Glucose
– Effective hemodynamic
Fact … of human brain
• Uses O2
20approx. % of tot al O2
• Uses glucose approx. 65% o f total glucose
• Uses approx. 20% of total ci / (750 ..)
Balance mechanism of :
•Hemodynamic•Respiration•Metabolism•Neurologic
Caused from impair……..– Hemodynamic– Respiration– Metabolism– Neurologic
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• Epilepsy• Hypoglycemic reaction• Acute adrenal
insufficiency
• Acute allergicreaction
• Acute myocardialinfarction
• Cerebrovascularaccident
• Hyperglycemicreaction
• Hyperventilationsyndrome
Alteration of consciousness
• Cerebrovascular accident (CVA)• Seizures• Hypoglycemia / Hyperglycemia• Adrenal insufficiency• Thyroid storm• Hyperventilation• Drug overdose
Syncope is the most common occurred.
Factors influence
•Stress and anxiety
•Health status•Drugs
How syncope occur?
In normal : circulation compensation mechanism play role in correction of deficiency O2 supply to the brain.
In syncope : circulation compensation mechanism fail to increase O2 need from the brain
How syncope occur?
Early :Feeling of warmthLoss of color : pale or ashen=gray skin tone
Heavy perspirationComplaints of feeling “bad” of “faint”
NauseaBlood pressure approximately baseline
Rapid heart rate
Signs for syncope
Signs for syncope Late :
– Pupillary dilation– Yawning– Hyperpnea– Cold hands and feet– Hypotension– Bradycardia– Dizziness– Loss of consciousness
Critical consideration•Timing of detection and
correction•Maintain O2 level to the
brain : Airway, Breathing, Circulation (ABC - Basic life support)
Orthostatic hypotension
• Failure of the baroreceptor reflex
• Loss of compensate mechanism
• Reflex bradycardia
• Loss of consciousness
Dr ugs pr oduci ng or t host at i c hypot ensi on
Category Generic name Proprietary name
Antihypertensives Guanethidine I smelin
Phenothiazines ChlorpromazineThioridazine
ThorazineMellaril
Tricyclicantidepressants
DoxepinAmitriptylineI mipramine
SinequanElavilTof ranilPresamine
Narcotics MeperidineMorphine
DemerolMorphine
Antiparkinson drugs Levodopa (L-dopa) DoparLarodopa
UnconsciousnessAssessment : 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 activationA, B = Airway (head
tilt - chin lift) Artificial Assisted Breathing (if
no self respiration)
C = check circulation
Carotid pulse present
Carotid pulse absentCheck
medical history Vital signs
Activate EMS
Recovery
unrecovery Initiate
CPR Immedi
ate transportation
Vasodep ressor
syncope
Ortho static
hypotension
Sequence of BCLS•Assessment•EMS Activation•ABCs of CPR•D of Defibrillation
ABCs of CPR•Airway•Breathing•Circulation
Airway•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
mechanismMechanismInadequate delivery
of blood or oxygen to the brain
Clinical example Acute adrenal
insufficiency Orthostatic
hypotension Vasodepressor
syncope
MechanismSystemic or local
metabolic deficiencies
Clinical example Acute allergic reaction
Drug ingestion andadminstration
Nitrites and nitratesDiuretics
-Sedatives narcotics Local anesthetics
HyperglycemiaHyperventilationHypoglycemia
Classification of causes of unconsciousness by
mechanism
MechanismDirect or reflex
effects on nervous system
Psychic mechanisms
Clinical example Cerebrovascular
accident Convulsive episodes
EmotionaldisturbancesHyperventilation
Vasodepressor syncope
Classification of causes of unconsciousness by
mechanism
Causes of chest pain
Cardiac related
• Angina pectoris
• Myocardial infarction
- Non cardiac related• Muscle strain• Pericarditis• Esophagitis• Hiatal hernia• Pulmonary embolism• Dissecting aortic
aneurysm• Acute indigestion• Intestinal “gas”
Chest pain is one of the major clinical clues to the presence of significant heart disease.
Definition of Terms“Atherosclerosis” is a special typ
e of thickening and hardening of - medium sized and large arterie
s because of deposits of a fatty substance.
• is an ongoing process• is a reactive biologic response of art
eries to the forces being generated by the flow of blood.
Atherosclerosis is the major factor un
derlying all forms c ardiovascular disea
se.
Normal structure
Development ofatherosclerosis
Proliferativ e change
Development ofatherosclerosis
Lipid deposition
The development of ACS
Early plaque formation
Significant plaque formation
Plaque rupture
Thrombus
Coronary arterydisease is the prese
nce of atherosclerosi s in the coronary art
eries.• 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.
Myocardial infarction 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 co
ronary artery caus ed by atherosclero sis and thrombus f
ormation.
Unstable angina•Angina that is continuing, prolonged or occurring at rest.
•Represents a syndrome that lies between angina pectoris and AMI.
Angina pectoris --------------> AMI
Unstable
Angina
Risk factors : Heart attack•Risk factors that cannot
be changedAgeHeredityGenderRace
• Risk factors that can be changed
Cigarette smoking
High blood pressure
High blood cholesterol level
Physical inactivity
DiabetesObesityExcessive stress
Diagnosis Electrocardiogram
(EKG) Exercise stress test
Echocardiogram Coronary angiography
Treatment 1. Coronary artery bypass graft
sssssss () 2. Medical therapy 3. Percutaneous Transluminal Cossssss sssssssssss (PTCA)
หร�อ Percutaneous Coronary Intervention (PCI)
Drugs and bleeding in patient with CAD•Aspi r i n•Plavix•Ti cl i d•Coumadin
Angina pectoris•Potential problem related to dental care1. Stress and anxiety related to dental visit may precipitate angina attack
2. Myocardial infarction3. Sudden death
Angina pectoris
•Prevention of complication1. Detection of patient2. Referral of patient for medical evaluation and treatment
• Prevention of complication 3. Known case with medical treat
s sss sss ssssss–ssssss sssssssss ssssssss
•Premedication• Open and honest communication• Morning appointments• Short appointments• - Nitrous oxide oxygen
–sssss sssssssss ss sssss ss sssssssssss
Emergency action plan for a person with signals of heart attackUnknown 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 care1. Cardiac arrest2. Myocardial infarction3. Angina pectoris4. Congestive heart failure5. Bleeding tendency secondary to anticoagulant
• 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 essssssssss 5. Check PT s sss(cation)
Management of Acute Myocardial Infarction
Step 1. DiagnosisAdminister nitroglycerin 2. Initiate BLS 3. Summon medical assistance 4. Administer oxygen and monitor vital signs 5. Relive pain Morphine Nitrous oxide - oxygen 6. Transport patient to hospital
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Medical Problem List
1 . Cor onar y ar t er y di sease : - doubl e vessel
Status: post PCI พ.ค . + ม�.ค . 4 6at present : asymptomatic
2. DM : controlled3. HT : controlled
4. Ol d CVA : Left hemiparesis 5
yrsago at pr es ent: compl et er ecover y
5 . Mild renali nsuffi ci ency 6. Mild late onsetast hma
Current medication 1. Aspent gr. V 1 1x orally
. 2. Plavix 1 1x orally pc.
3. Plendil 1 2x orally pc. 4 . Minidiab 1 1x orally pc.
5. Bestatin 1 1x orally pc. 6 . Singvalac 1 1x hs.