medical emeregency
TRANSCRIPT
April 7, 2023 1
MEDICAL EMERGENCYIN THE DENTAL OFFICE
Angkatan XPembimbing : drg. Aries M., sp.BM
April 7, 2023 2
Emergency : a situation and condition that threatening/endanger life
Dental emergency : a life threatening situation that frequently occuring in dental office
“Dental conditions are not usually dangerous to life, but they are often exceedingly painful”
J.N.W. McCagie, Oral Surgeon
April 7, 2023 3
TOPICS
• Introduction– Basic principles emergency management
• Emergencies status– Pre op emergency– Durante op emergency– Post op emergency
• Drugs related
April 7, 2023 4
• Morbidity accident in dental practice(1985-2000=30.608 px)– Syncope 15,4%– Allergic rx. 2,6%– Angina 2,5%– Hypotension 2,4%– Seizures 1,5%– Asthma 1,3%– Anaphilactic 0,3%– DM &overdose LA 0,2%– Heart failure 0,1%
INTRODUCTION
Stanley malamed, 2000
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• Emergency complication in dental practice :– During tx 129 case– Before & after tx 45 case
• Occurance of systemic complication :– During/after LA 55%– During tx 22%– After tx 15%– After leaving dental office 5,5%
INTRODUCTION
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• Treatment perform complication in dental practice (dental surgery) :– Extraction 39%– Unknown causes 12%– Incision 1,7%– Apico/root surgery 0,7%
INTRODUCTION
Stanley malamed, 2000
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INTRODUCTION
Basic Principles of Medical Emergency ManagementPrevention is the most important phase of treating, include :1. Medical history2. Px evaluation :a. visual inspection
b. vital sign c. medical treatment
3. Treatment management
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• Prevention– Do physical examination– Medical history anamnesis– Vital sign : BP, HR, RR, T– Prophylactic?– Pain control– Duration of action– Post op monitoring
INTRODUCTION
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PREVENTION
Stanley malamed, 2000
a. sphymomanometer
b. Mercury gravity manometer
c. Correct ear loop direction stetoscope
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PREVENTION
a. Proper placement of BP cuff
Important things:A. Px’s arm rest at level
of the heartB. Lower cuff +-1inch
from antecubital fossa
C. A.BrachialisD. HR? beat/min.E. Rhythm?re/irre?F. Slow release 2-3
mmHg/s.G. 1st sound=systole
Stanley malamed, 2000
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PREVENTIONblood pressure guidelines (ASA 2002) and dental therapy considerations
Blood pressure in adults, based on ASA 2002
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· <140/<90check annually
· 140-160/90-100recheck at 3 visits if no change medical consult concurrent with dental treatment.
· 160-200/100-115recheck in 5 minutes, no dental treatment and medical consult.
· >200/>115recheck in 5 minutes, no dental treatment and medical consult.
Lapointe, 2006
PREVENTIONblood pressure guidelines (ASA 2002) and dental therapy considerations
13
Situation Agent Dose regiment
General prophylaxis Amoxicillin -Adult:2 g, Children:50 mg/kg orally 1h before tx.
Inability oral medication Ampicillin -Adult:2 g IM/IV, Children:50 mg/kg IM/IV 30min before tx.
Penicillin allergy Clindamycin/
cefadroxil*/
azithromycin/ clarithromycin
-Adult:600 mg, Children:20 mg/kg oral 1h before tx.-Same as amoxicillin tx.
-Adults:500 mg, Children:15 mg/kg oral 1h before tx.
Penicillin alergy and inability take oral
Clindamycin/
cefazolin*
-Adult:600 mg, Children:20 mg/kg IV 1h before tx.-Adult:1 g, Children:25 mg/kg IM/IV 30min before tx.
Prophylaxtic agents
* Cepalosporins shouldn’t prescribe for immediate hypersensitivity reactions(urticaria, anaphylaxis)to penicillin s
April 7, 2023
Based on ASA 2002, general prophylactic agents., S.V.Mahadevan, 2005.
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Basic life support(cardiopulmonary resuscitation)
Look and see
• unresponse
Do what should to be
• Open airways
1st step
• 30 chest compressions
Next step
• 2 rescue breaths 30 compressions
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ASA level statusLevel Status
I Normal, healthy without systemic disease
II Px with systemic disease
III Severe systemic disease, limits activity but not incapacitating
IV Incapacitating systemic disease that constant threat of life
V Not expected to survive 24 h with/out an operation
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ASA level & disease exampleLevel Example condition
ASA I Green light, able to flight, no risk
ASA II Yellow light, well controled NIDDM, epileptic, asthma, hyper/hypotiroidsm, pregnancy, allergic, >60 years old, adults BP 90-94/140-159 mmHg
ASA III Stable angina, 6months post myocardiac infark, well controled IDDM, COPD, CHF, adults BP >95/160mmHg
ASA IV Unstable angina, MI/CVA within 6months, BP >115/200mmHg, uncontroled IDDM&epilepttic, severe COPD
ASA V End stage cancer, renal disease, cardiovasc, hepatic disease
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GCS indexEye opening Motoric response Verbal response
Spontaneously 4 Obey 6 Oriented 5
To speech 3 Localizes pain 5 Confused 4
To pain 2 Withdraws from pain 4 Inappropriate 3Kata2 tidak tepat
None 1 Flexion to pain 3 Incomprehensible 2Tidak jelas
Extension to pain 2
None 1
None 1
s.v.mahadevan., 2005
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• General treatment principles
* it is imperative to address life threats first to treat emergency patient.s.v.mahadevan., 2005
BASIC PRINCIPLE OF MEDICAL EMERGENCY MANAGEMENT
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Airway management• Timely effective airway management can mean the difference
between life and death,
s.v.mahadevan., 2005
April 7, 2023 20s.v.mahadevan., 2005
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BASIC PRINCIPLE OF MEDICAL EMERGENCY MANAGEMENT
1. Medical history– S : symptoms– A : allergy– M : medical status– P : previous history– L : last incident– E : event leading problems
Lapointe, 2006
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Medical historyBased on American Dental Association, stanley malamed., 2000
April 7, 2023 23Based on American Dental Association, stanley malamed., 2000
April 7, 2023 24
2. Px evaluationa. Visual inspection of the px.b. Record vital signs.c. Complete medical treatment.
BASIC PRINCIPLE OF MEDICAL EMERGENCY MANAGEMENT
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Visual inspection in life threatening status1. BLS: remember ABC’s2. Place the patient supine.3. Maintain airway (o2 if needed).4. Monitor vital signs.5. Initiate specific treatment6. prepare for assisted.7. Prepare informed concent !
Lapointe, 2006
BASIC PRINCIPLE OF MEDICAL EMERGENCY MANAGEMENT
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2a.Visual Inspection ( emergency / usual treat? )should examine head to toe over px.
BASIC PRINCIPLE OF MEDICAL EMERGENCY MANAGEMENT
A B
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Which One Who’s Need To Treat 1ST?
A B
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TRAFFIC INCIDENTS, NEEDS RAPID TREATMENT
(emergency status)
B
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2b. Vital Sign
BASIC PRINCIPLE OF MEDICAL EMERGENCY MANAGEMENT
s.v.mahadevan., 2005
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GCS• Mild : 14-15• moderate : 9-13• severe : 3-8
GCS = E+M+V
Adapted from Teasdale G and Jennett B.9
BASIC PRINCIPLE OF MEDICAL EMERGENCY MANAGEMENT
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2c. Medical treatment examination– Cito?– Elective surgery?– Medication?– Consult?
BASIC PRINCIPLE OF MEDICAL EMERGENCY MANAGEMENT
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EMERGENCY STATUS(SYNCOPE)
What is the most common problems that we could face as a dentist practicioner?
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EMERGENCY STATUSSYNCOPE
• Three phase– Pre syncope : warm feelings, lightheaded, dizzy,
midriasis, increasing HR, sweating.– Syncope : brachycardia, loss of consciousness,
seizures.– Post syncope : variable to mental confusion,
blood pressure back to normal.
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SYNCOPE-UNCONSCIOUSNESS
• SyncopeStridor, wheeze,
respiratory distress orclinical signs of shock #2
For hypotension, lie patient flatwith legs raised
(unless respiratory distress increased)
Adrenaline #31:1000 solution
0.5 mL (500 micrograms) IM #4
Repeat 5 minutes for resurection if no response
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1. Stop all dental treatment.2. ABC’s, ensure that the airway is open.
(Remove all objects form the patient’s mouth).3. Place patient in supine position with legs and
arms elevated and head at level of heart (If patient is pregnant roll onto left side).
4. Use Ammonia ampule to stimulate breathing.
MANAGEMENT OF SYNCOPE/UNCONSCIOUSNESS
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5. Oxygen 3-5L/min by nasal canula or 10L/min by mask.
6. Reassess airway.7. If unconscious for more than 1 minute
activate EMS.8. Start IV if available.9. Augment ventilation if respiratory effort is
poor (Use Ambu bag.)10. Reassess airway every 30 seconds.
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• Differential diagnosis :– Stress– Postural hypotension
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EMERGENCY STATUSALLERGIC REACTION &DRUGS INDUCED
Often due to anaphilactic shock, over treatment, dosage passage (local anaesthethic), antibiotics?
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Signs and Symptoms:1. Cutaneous reactions are the most common occurrence
and include urticarial.2. Angioedema (Swelling) this varies from localized slight
swelling of the lips, eyelids, and face to more uncomfortable swelling of the mouth, throat, and extremities.
3. Respiratory (Tightness in chest, sneezing, bronchospasm).
4. Ocular reactions include conjunctivitis and watering of eyes.
5. Hypotension.
ALLERGIC REACTION
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CLINICAL EXAMPLES ALLERGIC DISEASE
• Anaphilaxis (drugs, venom inject)• Atopic bronchial asthma• Allergic rhinitis• Urticaria• Allergic contact dermatitis• Tissue graft rejection• Tuberculosis mycose
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ADVERSE DRUGS REACTION CLASSIFICATION
Directly extension of pharmacologic effect :Side effect, overdose, local toxic effect
Altered recepient (patient) :Presence pathologic processes, emotional disturbances, genetic abbernations (idiosyncrasy), teratogenicity, drugs interactions
Drug allergy
Adapt from Pallasch T.J in Stanley malamed, 2000.
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DEFINITION ALLERGIC REACTION
• Overdose rx. : a condition that result from exposure to toxic amounts of a substance that doesn’t cause adverse effect when administered in a smaller amounts.
• Allergy : hypersensitive response to an allergen to which that individual previously exposed and has antibodies developed.
• Idiosyncrasy : an individual’s unique hypersensitivity to a particular food, drugs/ other substance.
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CLASSIFICATION OF ALLERGIC DISEASEType Mechanism Antibody/cell Time reactions Clinical features
I Anaphylactic(antigen induced-antibody mediated)
Ig E Second to minutes
Anaphylaxis, atopic bronchial asthma, allergic rhinitis, urticaria, angioderma, hay fever
II Cytotoxic(antimembrane)
Ig GIg M (activate complements)
- Transfusion reaction, hemolytic anemia, autoimmune hemolysis, certain drug reaction
III Immune complex(serum sickness like)
Ig G (form complexes + complements)
6-8 hour Glomeluronephrosis, Lupus nephritis, acute viral hepatitis, serum sickness
IV Cell mediated - 48 hour Allergic dermatitis complex, tissue rejection, chronic hepatitis, TBC, mycosis
Based on Krupp., Chatton in Stanley malamed, 2000.
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• Allergic reaction is an exaggerated or inappropriate immune reaction and causes damage to the host
• Hypersensitivity:
– Type I: anaphylactic reaction: mediated by IgE antibodies, which trigger the mast cells and basophils to release pharmacologically active agents.
– Type II: cytotoxic reaction: IgM or IgG antibodies bind to antigen on the surface of cells and activate complement cascade.
ALLERGIC REACTION(Type)
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– Type III: Immune complex reaction: complexes of antigen and IgM or IgG antibodies accumulate in the circulation or in tissue and activate the complement cascade. Granulocytes are attracted to the site of activation and release lytic enzymes
– Type IV: cell-mediated immunity reaction: mediated by T cells, which release cytokines upon activation to cause accumulation and activation of macrophages.
ALLERGIC REACTION(Type)
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DRUGS INDUCED ALLERGY & IT’S SUBTITUTES
• Antibiotic…………………………………………..– Penicillins, Cepalosporins,
Tetracyclines, sulfonamides• Analgetic……………………………………………
– Aspirin, NSAIDs• Opioid……………………………………………….
– Morphine, meperidine, codein• Antianxiety…………………………………………
– barbituirates• LA………………………………………………………
– Esters: procaine• Other…………………………………………………
– acrylic
• Erythromycin
• Acetaminophen• Opioid – NSAIDs
• diazepam/flurazepam• Sodium bisulfite – non
vasopressor LA• Acrylic – heat curing/
avoid at all
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LOCAL ANESTHETIC OVERDOSEmild overdose with rapid onset
Sign&symptoms
1. Onset 5-10 min. after drug adm.
2. Talkativeness.3. Increased anxiety.4. Facial muscle twicthing.5. HR, BP, Rr increased.
managements
1. Terminate dental tx.2. Positition.3. Reassurance px.4. ABC.5. Treat & medication:
1. O2 adm.2. Vital sign monitoring3. Anticonvulsan?
Diazepam/midazolam 2,5-5mg iv
4. Emergency transport if no reacting.
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Sign & symptom• Tender to unconsciousness.• Appear as second after
inject adm.• Tonic-clonic seizures
1. Idem poin 1-5 above2. If iv unavaliable: BLS3. Vital sign monitoring: if BP
remains depressed (>30min.) consider to give vasopressor (20mg methoxamine im, 1000ml of normal saline/ dextrose 5% iv infusion)
4. Ready to emergency transfer if no response.
LOCAL ANESTHETIC OVERDOSEsevere with rapid onset
managements
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VASOCONSTRICTOR OVERDOSE
Clinical manifestations1. Increase BP, HR (palpitation)2. Fear3. Anxiety4. Tenseness5. Restlessness6. Tremor7. Headache/dizzyness8. Perspiration9. Pallor10. Respiratory distressed11. sweating
managements1. Idem poin 1-5 above2. If respiratory distressed : o2
canule, hood/full mask needed.
3. Vasodilators (optional) : BP HR doesn’t begin to return, nitroglycerin 2x spray translingual (beware of postural hypotension).
4. Ready to emergency tranport.
April 7, 2023
VASOCONSTRICTORS(COMMONLY USE)
Agents [ ] Dilutions Max dose Mg/ml Mg/Cartridges (1,8ml)
Max cartridges
Ephinephrine(lidocain 2%)
1:50K1:100K1:200K
--
1:100K
1:200K
H=0,2mgC=0,04mg
--
0,01
0,05
--
0,18
0,09
H=10; C=2
H=20; C=4
Stanley malamed,2000. 50
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Drugs Dose mg/kg Absolute max dose
Lidocaine 4.4 300 Lethal
Mepivicaine 4.4 300 Lethal
Prilocaine 6.0 400 Lethal
Bupivicaine 2.0 90 Lethal
Etido/articaine 7.0 500 lethal
VASOCONSTRICTORS(maximum dose)
Stanley malamed,2000.
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BMJ Journals, visual diagnosis and critical care medicine., 2006
Skin rash / Urticaria
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General Treatment1. ABC’s2. Maintain airway, administer oxygen, and
determine possible need for intubation or surgical airway.
3. Monitor vital signs.4. If in shock put patient in a horizontal or slight
Trendelenburg position.
ALLERGIC REACTION(Management)
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A. Insertion o2 maskB. supine/trandelenberg postioning
BMJ Journals, visual diagnosis and critical care medicine., 2006
April 7, 2023 55
Emergency statusallergic rx.
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ALLERGIC REACTIONskin reaction
• Terminated dental procedure
• Positioning• ABC• D: definitve care
– Observe– Histamine blocker oral
• Terminated dental procedure
• Positioning• ABC• D: definitve care :
– No cvs : poin 1.– CVS :1. Adm. Epinephrine (sc, im,
iv)2. Adm. Histamine blocker
Management rapid onset skin allergic reaction
Management elayed onset skin allergic reaction
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ALLERGIC REACTION
BMJ Journals, visual diagnosis and critical care medicine., 2006
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SHOCKOther type allergy
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SHOCK
• Shock?– inadequency of blood flow throughout the body
to the extent that the body tissue are damaged because of too little flow, especially too little delivery of oxygen and other nutrients to tissue cell.
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SHOCK
HYPOVOLMIC CARDIOGENIC
ANAPHYLACTI
C
SEPTICEMIC
NEUROGENIC
DISTRIBUTIVE
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• Cause of shock– Reduced venous return following haemorrhage.– Cardiogenic shock from ischaemic heart disease
and cardiac contusions.– Reduced arterial tone complicates spinal injury
above T6 by impairing sympathetic nervous system outflow from the spinal cord below that level.
– Septic shock results when circulating endotoxins.
SHOCK
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PATHOGENESISHYPOVOLUMIC & SEPTIC
DECREASED EFFECIENCY CIRCULATING VOLUME
DECREASED VENUS RETURN TO HEART
DECREASED CARDIAC OUTPUT
DECREASED BLOOD FLOW
DECREASED SUPPLY OF OXYGEN
ANOROXIA
SHOCK
journal of dentistry, BMJ volume 111 no.2, februari 2003
April 7, 2023 63
Anaphylaxis: This is a severe systemic type allergic reaction and is a medical emergency.
Signs and symptoms include:1. Cardiovascular shock including; pallor, syncope, palpitations,
tachycardia, hypotension, arrythmias, and convulsions.2. Respiratory symptoms include; sneezing, cough, wheezing,
tightness in chest, bronchospasm, laryngospasm.3. Skin is warm and flushed with itching, urticaria, and
angioedema.4. Nausea, vomiting, abdominal cramps, and diarrhea also
possible.
..anaphilactic
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Management• Lay flat with raised legs• Give Adrenaline (1:1000) 0.3-0.5 ml SC or IM• Hydrocortisone 200 mg i.v.• Chlorpheniramine 10-20 mg slow i.v.• Give oxygen 6L/min & assisted ventilation• Consider Cricothyrotomy if NO quick
improvement?
..anaphilactic
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Teratment.• For severe reactions, (i.e., collapsed, semi-conscious
patient, or those with severe bronchospasm and widespread rash) adrenaline given intramuscularly in a dose of 500 micrograms (0.5 mL adrenaline injection of 1:1000); an autoinjector preparation delivering a dose of 300 micrograms (0.3 mL adrenaline injection 1:1000).
• The dose is repeated if necessary at 5 minute intervals according to blood pressure, pulse and respiratory function.
anaphilactic
April 7, 2023 66
Consider diagnosis of anaphylaxis when compatible history of severe allergic-type reaction with respiratory difficulty and/or hypotension especially if skin changes present
Stridor, wheeze,respiratory distress or clinical signs of shock #2
For hypotension, lie patient flat with legs raised (unless respiratory distress increased)
Adrenaline 1:1000 solution
>12 years: 500 micrograms IM (0.5 mL) 250 micrograms if child is small or prepubertal #3 6-12 years: 250 micrograms IM (0.25 mL)
April 7, 2023 67
SIGNS AND SYMPTOMS VASOCONSTRICTORS TOXICITY
Adverse Drug ReactionsLocal Anesthetic and Epinephrine ToxicitySigns and Symptoms of Epinephrine Toxicity1. Agitation, weakness, and headache.2. Pallor, tremor, palpitation.3. Sharp rise in blood pressure and heart rate.
April 7, 2023 68
managements
MANAGEMENT OF TOXIC REACTIONS TO EPINEPHRINE: toxic effect ofepinephrine is transitory rarely lasting more than a few minutes
1. Stop dental treatment.2. Place patient in most comfortable position.3. Monitor vital signs.4. Consider administering oxygen.5. Allow time for the patient to recover.
April 7, 2023 69
LOCAL ANAESTHETICUM TOXICITY
Signs and Symptoms of Local Anesthetic Toxicity1. Agitation.2. Muscular twitching and tremors.3. Increased blood pressure and heart rate.4. Light-headedness.5. Visual and auditory disturbances (Tinnitis, Difficulty
focussing.)6. If moderate to high overdose of Local anesthetic can
also have convulsions and depression of blood pressure, heart rate, and respiration.
April 7, 2023 70
Managements
Treatment varies with the onset and severity of the reaction.MILD REACTION/RAPID ONSET (Example is an intravascular injection)
1. Reassure patient.2. Administer Oxygen.3. Monitor and record vital signs.4. Allow for recovery; determine if patient can be
allowed to leave unescorted.
April 7, 2023 71
Managements
• SEVERE OVERDOSE/RAPID ONSET, SEVERE OVERDOSE/SLOW ONSET
1. ABC’s.2. Administer Oxygen by mask at 10-15L/minute.3. Start IV if available (18 gauge catheter with Normal
Saline.)4. If needed and available administer anticonvulsant, Versed
2mg, then 1mg/min to effect (Monitor respiration.)5. Monitor and record vital signs.6. Allow for recovery and discharge with appropriate escort
or transport to hospital if required.
April 7, 2023 72
Max dose LA & vasoconstrictors
• Maximum Recommended Doses of Local Anesthetic• Lidocaine “Plain” 4.4mg/kg• Lidocaine 2% with 1:100k Epinephrine 7.0mg/kg• Mepivicaine “Plain” 4.4mg/kg• Mepivicaine with 1:20k Neocobefrine 6.6mg/kg• Bupivicaine with 1:200k Epinephrine 3.2mg/kg• Maximum Recommended Doses of Epinephrine• Healthy Adult 0.2mg• Cardiac Patient 0.04mg
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HEART DISEASE
April 7, 2023 74
AnginaSigns and Symptoms of Angina1. Sub-sternal/retro-sternal pain that spreads across the chest and
may radiate to arm/shoulder any area above the diaphragm.2. May vary from a heavy squeezing pain to a pressure or heavy
sensation in the chest.3. Pain usually lasts for a few minutes and disappears with rest;
can last for up to 60 minutes.4. Other symptoms such as palpitations, faintness, dizziness,
dyspnea, and digestive disturbances may accompany angina.5. vomit?
Signs and symptoms
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MANAGEMENT OF ANGINA1. Stop all treatment and stimulation of the patient.2. Position the patient comfortably; sitting upright is usually
preferred.3. Administer Oxygen via mask at 10-15L/min.4. Administer one tablet of Nitroglycerin 0.4mg sublingual or
one metered dose spray. If using tablets do not touch use gloves. Nitroglycerin can be absorbed through the skin.
5. If no relief after two minutes repeat Nitroglycerin. Can repeat a third time if no relief. Monitor blood pressure after each dose; do not repeat dose if systolic BP drops below 100.
6. Monitor and record vital signs.7. If no react after given 3rd dose nitro, susp. MI?
managements
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Miocard infark
Signs and Symptoms of a Myocardial Infarction (Heart Attack)1. Often preceded by a history of angina.2. Pain usually described as heavy, squeezing, pressing, or
crushing in nature. Pain is located over middle third of sternum.
3. Pain is not relieved by nitroglycerin and is longer in duration than angina (Angina generally last 30 minutes to one hour.)
4. Silent MI (No pain) occurs in 15-20% of cases though they may suffer from nausea, vomiting, weakness, and anxiety.
April 7, 2023 77
5. weakness, diaphoresis, and hypotension.6. Patient is often restless, moving about in an attempt to find a
comfortable position.7. Dyspnea is present as patient complains that crushing pressure prevents
normal breathing.8. Levine’s Sign.9. Shock occurs in 20% of cases.10. Cardiac arrhythmias occur in 95% of patients suffering from a MI.11. Arrhythmias usually occur within the first two hours after onset of the
MI.12. Ventricular fibrillation is the most common arrhythmia. This is an
uncoordinated contraction of individual muscle bundles within the myocardium resulting in the inability of the heart to pump blood.
13. Cardiac arrest is the result and must be converted to a normal rhythm as soon as possible.
Signs and Symptoms of a Myocardial Infarction (Heart Attack)
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MANAGEMENT OF A SUSPECTED MYOCARDIAL INFARCTON1. Discontinue all treatment2. Clear the mouth of all foreign material.3. Place patient in a comfortable position (Usually upright.)4. Administer Oxygen at 10-15L/min.5. Monitor and record vital signs every 5 minutes (Including
blood pressure, pulse, and respiration rate).6. Give the patient an aspirin (325mg) if available and have them
chew it and allow it to absorb through the oral mucosa.7. If equipment available start an IV (18guage catheter with
Normal Saline.)
managements
April 7, 2023 79
8. If equipment available attach cardiac monitors.9. If a provider is properly trained and equipment is
available proper ACLS protocols should be initiated.11. If patient looses consciousness initiate proper BLS
protocols.TRANSPORT: In the case of a MI the earlier the
patient is transported to a hospital and definitive treatment begun the better the chance the patient will survive with minimal cardiac damage.
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Emergency statusangina (heart attack)
April 7, 2023 81
April 7, 2023 82
DIABETICPre operative
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Emergency statusPRE OPERATIVE
• DM– Acute complication : hyper/hypoglicemia– Chronic complication : arteriosclerosis,
microangiopathiWhat is normal value of normal glucose tolerance?Fasting plasma glucose(mg/dL) = <115Tolerance 116-139>140 = diabetic
• In nondiabetic patients, 2-hour postprandial blood glucose levels are usually <120 to 140 mg/dL.
Stanley malamed, 2000
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• DM classification– DM type I : IDDM– DM type II : NIDDM
• Non obese• Obese
– Other type : associated with other condition and syndrome (pancreatic disease, hormonal ethiology, drug induced, insulin receptor, abnormalities, genetic/pathologic syndrome)
Stanley malamed, 2000
Emergency statusPRE OPERATIVE
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Normal Values• Normal fasting glucose: FPG<100 mg/dL (<5.6
mmol/L SI units)• Impaired fasting glucose: FPG 100–125 mg/dL
(5.6–6.9 mmol/L SI units)• Provisional diagnosis of diabetes: FPG ≥126
mg/dL (≥ 7.0 mmol/L SI units) (diagnosis must be confirmed)
PRE OPERATIVEdiabetic
Stanley malamed, 2000
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• Glucagon:causes the blood sugar to rise by speeding the breakdown of glycogen in the liver.
• Insulin allows : glucose to pass into cells for use as energy, leading to a decrease in the blood glucose.
• The maintenance of normal blood glucose is dependent upon proper functioning of two hormones.
PRE OPERATIVEdiabetic
April 7, 2023 87
PRE OPERATIVEdiabetic
Stanley malamed, 2000
Blood glucose check
April 7, 2023 88
Robins & cotrans, 2003
April 7, 2023 89
HYPERGLICEMIA
• Chronically ill.• Dry appearance, warm skin.• Odor acetones breath.• Blood Glucose level >250 mg/dl.• Blood pH ,7,3• Usually develop over a period many hour/day.• Kussmaul’s respiration.• Altered level of consiousness.
April 7, 2023 90
HYPERGLICEMIAMANAGEMENTS
Hyperglycemia (unconscious)
1. Terminate dental tx2. P: Positioning supine3. ABC: BLS needed4. D: Definitive initiating
care, maintain O2, establish IV, tranfer to Hospital if no response
Hyperglycemia(conscious)
1. Clinical sign&symptom recognized(level ASA4) : hi risk, shouldn’t receive dental tx
2. Medication& supportive tx.
3. Consult?
April 7, 2023 91
Optimal ASA physical status to diabetic conditions management
• Type I IDDMinsulin+diet control
• Type II NIDDM non obeseinsulin+diet control
• Type II NIDDM non obeseOral medication+diet control
• Type II NIDDM obeseoral medication+diet control
III severity………………
II-III moderate to severe………………..
II mild to
moderate…………..
II mild to moderate…………..
Stanley malamed, 2000ASA: american society of anesthesiologists
April 7, 2023 92
GLUCOSE LEVELTO TREATMENT MEASUREMENTS
Urine glucosuria Blood glucose Physical status Comment0 <50 mg/dl + 1 May accept tx,
might become hypoglicemic
0+1+2
80 mg/dl120 mg/dl180 mg/dl
000
Accept dental tx
+3 240 mg/dl +1 Evaluate before tx
+4 >240 mg/dl +2 Medical consult before tx.
Stanley malamed, 2000
April 7, 2023 93
HYPOGLICEMIA
• Insulin shock?• Weakness, dizziness, pale, moist skin.• Normal/depressed breath.• Headache.• Altered level conscious.
April 7, 2023 94
HYPOGLICEMIAmanagements
Conscious&responsive px.1. Initial recognition2. Termination dental tx3. Potition (individual px.
Comfort, common up right)4. ABC5. D: definitive care, oral
carbo.?, observe
Unresponse conscious px.1. Idem to poin 1-52. If no response, parenteral
carbohydrates : glucagon 1mg/im/iv. 50ml of dextrose sol. Iv, 2-3 minutes. 0,5mg of 1:1000 ephinephrine sc/im, 15 minutes (careful to cardiovasc disease).
3. Monitoring px status, vital sign review.
April 7, 2023 95
Anti hypoglicemia preservation
HYPOGLICEMIAmanagements
Anti hypoglicemic agents
A
B
C
D
A. Dextrose inj. 50%B. Glucagon inj.C. Epinephrine inj.D. sugar
Stanley malamed, 2000
96April 7, 2023
• Hypoglicemia drugs & kit
HYPOGLICEMIAmanagements
a. Infusion set+glucose 20%b. Glucose 50% in minijet formatc. Glucose powder 20 grd. Glucagon emergency sete. Blood glucose test stickf. Oxygen mask
Robins & cotrans, 2003
April 7, 2023 97
LONG TERM COMPLICATION OF DIABETIC
Robins & cotrans, 2003
April 7, 2023 98
ASTHMAEmergency systemic conditions
April 7, 2023 99
asthma
• Is: chronic inflammatory disorders of the airway in which many cells and cellular elements play role.
• Chronic inflammation due to associated with hyperresponsiveness that leads to recurrent episodes of wheezing, breathlessness, chest tightness and coughing.
April 7, 2023 100
• Asthma attackSigns and Symptoms of an Asthma Attack1. Sense of Suffocation, patient will sit up like they are fighting
for air.2. Pressure or tightness in chest.3. Non-productive cough.4. Expiratory and inspiratory wheezes.5. Expiration is prolonged and harder than inspiration.6. Chest is distended.7. Thick Stringy mucous. At termination of a period of intense
coughing the patient will expectorate this mucous.
Emergency statusdurante op.
April 7, 2023 101
• Severe symptoms– Cyanosis– Perspiration and flushing of the skin.– Use of accessory muscle of respiration:
Sternocleidomastoid, and shoulder/abdominal muscles.
Emergency statusasthma
April 7, 2023 102
Emergency statusasthma
April 7, 2023 103
Management1. Discontinue dental treatment.2. Place patient in easiest position for them to breath.
This is usually upright with arms outstretched.3. Albuterol Inhaler (Proventil) 2 puffs every 2 minutes.4. Supplemental oxygen at 10L/min.5. Consider Epinephrine 1:1,000, 0.3g every 20 minutes.6. Monitor vital signs.
Emergency statusasthma
April 7, 2023 104
April 7, 2023 105
• If we already knew our px medical history1. Take a good Medical History prior to
treatment; determine how often the patient has an asthma attack and what precipitates it.
2. Consider scheduling morning appointments.3. If patient uses an inhaler they should have it
on hand during treatment. Consider prophylactic use prior to treatment.
Emergency statusasthma
April 7, 2023 106
TRAUMATIC INJURY
April 7, 2023 107
Emergency statusTraumatic injury
Primary survey:• Airway with cervical spine control• Breathing• Circulation with hemorrhage control• Disability• Exposure and environmental control
April 7, 2023 108
109
Emergency statustraumatic injury
a. Mastoids hematoma
Gus, M. Garrel. , 2005b. hemotympanum
c.
(C).
(A).
(B).
April 7, 2023 110
Malocclusion, indicated maksila/mandible/dentoalveolar fractures
Gus, M. Garrel. , 2005
April 7, 2023 111
Mechanism of traumatic and possible injuries
Gus, M. Garrel. , 2005
April 7, 2023 112
Gus, M. Garrel. , 2005
Emergency statustraumatic injury
April 7, 2023 113
Safety 1st
wear and click ur helmet
April 7, 2023 114
April 7, 2023 115
Emergency statuspost op.
• Bleeding• Trismus• Dry socket• Oro antral fistula
April 7, 2023 116
April 7, 2023 117
April 7, 2023 118
April 7, 2023 119
April 7, 2023 120
April 7, 2023 121
April 7, 2023 122
Drugs, emergency kit and preservation equipments
• O2 & mask
April 7, 2023 123
Asthma emergency kit
• Aerosol inhaler• Aminophilline 25
mg/mL• Isoproterenol 1mg/5 ml• epinephine
April 7, 2023 124
Antihypoglicemic agents
• Dextrose• Glucagon• Epinephrine• sugar
April 7, 2023 125
Blood gucose check
• Blood glucose tools
April 7, 2023 126
unconsious
• Inhaler amonia
April 7, 2023 127
April 7, 2023 128
SEIZURESunconsiousness
April 7, 2023 129
etiology
April 7, 2023 130
Predisposing factors
• Predisposing factors:• Anxiety• Hunger• Menstruation• Alcohol• External stimuli, flashing lights• Etc• Non compliance with• medications
April 7, 2023 131
Signs and symptoms
• Warning cry• Immediate loss of consciousness• Rigid (tonic phase)• Widespread jerking (clonic phase)• Vomiting• Flaccid after a few minutes• Consciousness is regained after a variable Period• Patient may remain confused
April 7, 2023 132
• Prevent patients from damaging• themselves• Place in Supine position• Maintain patent airway• No medications, await recovery• Recovery position after fits have ceased• Suctioning & Monitor VS• Oxygen• Reassure on recovery• After fully recovered requires an escort• Continuous or repeated convulsions for 15• minutes (patient can have severe anoxia)• Give 10mg Midazolam IV repeat if no• recovery within 10 minutes• Maintain airway & give oxygen• Call an ambulance, transfer to hospital
April 7, 2023 133
managements
April 7, 2023 134
Drugs treatment
April 7, 2023 135
Algoritm for seizures evaluation
April 7, 2023 136
Differential dx
April 7, 2023 137
• Clinical Surgery in General 4th ed. R.M.Kirk., W.J.Ribbans., Elsevier. 2004.
• Clinical problem solving in dentistry, 2nd ed. edward w. odell. Curchill livingstone., 2001.
• Stanley f. malamed., 2000.• John E Rowson, Adrian E Slaney, dentistry., cavendish pub.1996.• visual diagnosis in emergency and critical care medicine, bmj
books., blackwell pub.ltd.2006.• denise d. wilson., manual of laboratory and diagnostic tests.,
mc.graw hill. Company., 2008.• s.v.mahadevan., gus m. garrel., clinical emergency medicine.
Cambridge press. 2005.