Medical and dental emergencies and complications in

dental practice and its management

The medical and dental emergencies that are commonly encountered in dental practice involve:

syncope,

airway obstruction,

anaphylaxis,

local anesthetic toxicity,

Asthmatic attack,

chest pain,

hemorrhage,

seizure.

Myocardial

infarction and cardiac arrest are extremely rare.

SYNCOPE

Syncope is caused due to inadequate cerebral perfusion.

Causes of sudden loss of consciousness and collapse include

hypotension,

adrenal crisis,

anaphylaxis,

cardiac arrest,

diabetic collapse, hypoglycemia, epileptic seizure, fainting,

or stroke

THE EARLY MANIFESTATIONS

nausea,

warmth,

perspiration,

baseline blood pressure,

and tachycardia

LATE MANIFESTATION

hypotension,

bradycardia,

pupillarydilation,

peripheral coldness,

visual disturbance

MANAGEMENT:

The patient should be in the supine position

Recovery is almost instantaneous if the

patient has simply fainted.

Then maintain airway, check pulse (if

absent,

indicates cardiac arrest), and start CPR

immediately

SYNCOPE MANAGEMENT : TRENDELENBURG

POSITION

AIRWAY OBSTRUCTION

Airway obstruction is usually caused due to accidental slippage,

aspiration of foreign objects,

or laryngeal spasm. Patient

manifests with :

inability to speak, grasps the throat (universal

sign), coughs, inability to exchange air (in spite of respiratory movements), cyanosis, and loss of consciousness. These might eventually lead to cardiac arrest finally.

MAMAGEMENT

Main priority is to clear the airway, but the

method differs depending upon whether the

patient is conscious or unconscious.

If the patient is conscious, then

he/she must be made to sit straight, support chest with one

hand, and deliver five sharp back blows between the shoulder blades with the heel of the other hand. But if the patient is choking, an attempt is made to expel the object with upward

thrusts using Heimlich thrust [Figure 3]. It acts as artificial cough that produces a rapid increase in intra-thoracic pressure

thus helping to expel the foreign body [Figure 4].

FIGURE 3

ASSESS SEVERITY FIGURE 4

Encourage cough and observe the

patient for ineffective cough

Sever airway obstruction(ineffective cough

Mild airway obstruction

(effective cough)

Unconscious start CPR

Conscious 5 back blow 5 abdominal

thrust

ANAPHYLAXIS

It is a hypersensitive state that results from

exposure to an allergen.

The most common allergen in a dental setup

is latex

MANIFESTATIONS

vary from a mild form where the patient presents with :

erythematous rash,

cyanosis, nausea,

vomiting,

tachycardia,

utricaria,

or angiodema

to a severe form which leads to:

airway obstruction or inadequate blood pressure and blood flow to the brain which is a life-threatening situation

MANASGEMENT

involves lying the patient in the supine

position with legs raised

, administer oxygen, and the drug of choice

being 0.5 ml of 1:1000 adrenaline IM or SC

MANAGEMENT OF ANAPHYLAXIS

LOCAL ANAESTHIA TOXICITY

Toxicity is usually either due to the local

anesthetic itself or the vasoconstrictor which

can be due to rapid infusion or failure to

aspirate before injection

GENERALLY

the reactions are self limiting. Toxicity

presents with :

talkativeness,

slurred speech,

anxiety,

confusion,

drowsiness, or even seizure and cardiac

arrhythmias in extreme cases.

monitor vital signs.

Administer oxygen and in adverse cases

administration of diazepam 5 mg slowly is

advised

ASTHMATIC ATTACKE

Anxiety, infection, exposure to an allergen or

drugs can precipitate an asthmic attack

The goal of management during an acute

asthmatic episode on a dental chair should

be to:

relieve the bronchospasm associated with

the attack

Hence, the patient should primarily be

relieved of irritants and all articles should be

removed from oral cavity.

Drug of choice is 2 puffs of albuterol

(bronchodilator)

. If no improvement isseen in 15 seconds

then administer 1:1000 adrenaline 0.5 ml

SC/IM and

if still no response is observed in 2-3 min

then

salbutamol slow IV injection is advised.[

CHEST PAIN

Factors that precipitate chest pain include:

angina,

acute myocardial infarction,

gastrointestinal reflux disease,

anxiety,

costochondritis and paroxysma

supraventricular tachycardia

Taking history from patients is very important

here

Quality of pain can also indicate whether the

patient is having

an angina or acute myocardial infarction. In

angina pectoris pain is significant but not

severe

whereas an acute myocardial infarction pain

generally radiates to left side of the body-left

shoulder, left mandible, left arm.[

For angina pectoris, drug of choice is a nitrate,

commonly nitroglycerine, sublingual tablet,translingual or transmucosal spray.

Management of a patient with suspected acutemyocardial infarction involves administration of

morphine, oxygen, nitroglycerine, and aspirin(MONA)

in addition to emergency medical service. If morphineis

unavailable, the specialist can also substitute nitrousoxide/oxygen in a 50:50 concentration

HEAMORRHAGE

as dental specialists deal with blood routinely and there are instances when significant bleeding could lead into an emergency. Emergency management begins by :

gently cleaning the mouth and locating the source of bleeding

and the application of cold compress,

pressure packs, or styptics(substance capable of stopping bleeding when applied to a wound)

.Suture the area under L.A when necessary.

Tranexamic acid –500 mg in 5 ml by slow IV injection is the drug ofchoice

SEIZURES

Patients who convulse in dental office

generally have a seizure history and are

often characterized as having epilepsy

MANAGEMENT

Place him in a spine position

Remove all instrument from his mouth

Clear airway

Loosen the closthes

If seizure continues for long, then the

condition is known as status epilepticus. This

is a life-threatening emergency and is best

managed with

I.V. diazepam 5 mg IV/IM or

by maintaining BLS( basic life support) till

patient is shifted to emergency medical care.

DM

Elevated glucose levels in blood and urine.

Persons diagnosed with Diabetes may suffer

from too high or too low blood sugar at times

depending on medications, food intake,

illness or stress

SIGN AND SYMPTOMS

Hypoglycemia: Hyperglycemia

- Rapid onset –within minutes - Slow Onset – hours or days or weeks

(can be fatal) - Hot, dry

- Nervousness - Flush malaise

- Pallor - Nausea vomiting

- Weak, dizzy - Stupor

- Hunger, nausea - Drowsy

- Mental confusion - Irritability

- Lethargy or belligerence - Headache

- Decreased rate of breathing - Acetone odor

- Increased heart rate - Decreased rate of breathing

- Decrease in blood pressure - Increased heart rate

- Seizures - Decrease in blood pressure

- Tingling sensation in feet/hands

- Loss of consciousness, coma

Treatment Precautions:

• Ensure patient has eaten and has had their medication before the appointment

• Keep appointments short

• Have a sugar supplement on hand

Treatment:

• If conscious and able to swallow well, give sugar supplement. Call EMS if patient doesn’t feel better

in 15 minutes or becomes unconscious.

• If unconscious call EMS immediately

Situation Agent Regimen

Standard general

prophylaxis

Amoxicillin Adults: 2g

Children: 50mg/kg

orally

1 hour before the procedure

Inability to take oral

medications

Ampicillin Adults: 2g

Children: 50 mg/kg

IM/IV

30 min before procedure

Allergy to penicillin Clindamycin or

Cephalexin/Cefadroxil or

Azithromycin/

Clarithromycin

Adults 600 mg

Children 20 mg /kg

Adults 2g

Children 50mg/kg

Adults 500 mg

Children 50 mg/kg

Orally

1 hour before the procedure

Allergy to penicillin and

inability to take oral

medications

Clindamycin or

Cefazolin

Adults 600mg

Children 20mg/kg

IV 30 min before

Adults 1g

Children 25 mg/kg

IM/IV 30 min before

BASIC LIFE SUPPORT (BLS)

Module one – critical or essential emergency drugs

Category Generic drug alternative quantity Availability

Allergy –

anaphylaxis

Epinephrine None 1 preloaded

syringe +3x1

ml ampules

1:1000

(1mg/ml)

allergy –

histamine

blocker

Chlorphenira

mine

Diphenhydra

mine

(Benadryl)

3x1 ml

ampules

10 mg/ml

Oxygen Oxygen 1 “E” cylinder

Vasodilator Nitroglycerin Nitrostat

sublingual

tablets

1 metered spray

bottle

0.4 mg /metered

dose

Bronchodilator Albuterol Metaproterenol 1 metered dose

inhaler

Metered aerosol

inhaler

Antihypoglyce

mic

Sugar Insta – glucose

gel

1 bottle

Inhibitor of

platelet

aggregation

Asprin None 2 packets 325mg/tablet

Module two – secondary/ noncritical drugs and equipment

Category Generic Drug Alternative Quantity Availability

Anticonvulsant Midazolam diazepam 1x5 ml vial 5 mg/ml

Analgesic Morphine

sulphate

Meperidine 3x1 ml ampules 10 mg/ml

Vasopressor Phenylephrine 3x1 ml ampules 10 mg/ml

Antihypoglycem

ic

50% dextrose Glucagon 1 vial 50 ml ampule

Corticosteroid Hydrocortisone

sodium succinate

Dexamethasone 2x2 ml mix- o –

vial

50 mg/ml

Antihypertensive Esmolol Propranolol 2x100 mg/ml

vial

100 mg/ml

Anticholinergic Atropine Scopolamine 3x1 ml ampules 0.5 mg/ml

Respiratory

stimulant

Aromatic

ammonia

2 boxes 0.3 ml/vaporole

Antihypertensive Nifedipine 1 bottle 10mg/capsule

Module three – Advanced Cardiac Life Support (ACLS) : essential

drugs

Category Generic Drug Alternative Quantity Availability

Cardiac Arrest epinephrine 3x10 ml

preloaded

syringes

1:10,000

(1mg/10ml

syringe)

Analgesic Morphine

sulphate

N2O – O2 3x1 ml ampules 10 mg/ml

Antidysrhythmic Lidocaine Procainamide 1 preloaded

syringe and 2x5

ml ampules

100 mg/ syringe

Symptomatic

Bradycardia

Atropine Isoproterenol 2x10 ml

syringes

1.0 mg/10 ml

Paroxysmal

Supraventricular

Tachycardia

verapamil 2x4 ml ampules 2.5 mg/ml

Establishing an emergency airway –

Non invasive procedures

Invasive procedures

example of how to place an unconscious

patient into the lateral recovery position – always ensure that the chin is

in an elevated position to maintain airway patency

DENTAL COMPLECATIONS

More than dental emergencies which require

an immediate attention and management,

the occurrence of “complications” are of

higher incidence in dental practice. The

complications may be immediate or delayed

and are related to patient’s tolerance level,

materials used and treatment procedures

ASPIRATION

Aspiration may be of:

the denture as a whole or a fractured part, a

minimal extension acrylic

removable prosthesis,

crowns during removal, I

nstrument

slippage especially broaches reamers or

files.

Aspiration causes:

airway obstruction which is manifested as the

universal sign“choking.”

Removal of broken instruments is performed

using:

ultrasonics, operating microscopes or

microtube delivery methods.

ALLERGY

Allergy can be to latex, mercury, rubber dam, and impression material

Manifestations of allergy include

pruritis,

erythema,

utricaria,

and angioneurotic edema.

latex-sensitive patients. Latex alternatives

(vinyl, nitrite, or silicone) and powder-free

gloves should be used to prevent

sensitization

Fixers like formacresol and devitalizers to be

used carefully to prevent chemical burns.

Complications involving local anaesthetics

are hypersensitivity, toxic reactions

MANAGEMENT

administering prophylactic antihistamines,

such as diphenhydramine

or corticosteroids such as prednisone before

dental treatment to those at known

Risk

and the drug of choice is 0.3-0.5 ml

intra-muscular or subcutaneous doses of

1:1000 epinephrine

Allergic reactions can also occur to acrylic

resins, which can be minimized by:

following proper monomer polymer ratio,

correct curing cycle so as to minimize the

residual monomer content in the prosthesis

PACEMAKERS AND THE DUAL-CHAMBER ICD

Operation of:

the electric toothbrush,

electrosurgical unit,

electric pulp tester,

high- and low-speedhandpiece, and an amalgamator did not alter pacing function.

the use of the ultrasonic scaler,

ultrasonic cleaning system,

battery-operated composite

curing light may produce deleterious effects in patients who

have pacemakers or ICDs.

HYPOCHLORITE ACCIDENT

wherein sodium hypochlorite is expressed

beyond the apex and patients manifests with

severe pain,

swelling

profuse bleeding.

MANAGEMENT

administration of a regional block and then

wait till maximum drainage occurs.

Antibiotics:

Penicillin 500 mg five times a day for 7 days

is prescribed.