Medical EmergenciesLecture 2

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Syncope (cerebral ischemia)

Sudden, transient loss of consciousness and postural tone with spontaneous recovery

Possible causes loss of cerebral oxygenation and perfusion Often sign of another underlying condition Often associated with a stressful condition

Most common medical emergency in the dental office Most syncopal episodes occur during the administration of local

anesthetics

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Syncope Affects all age groups More susceptible in children, pregnant mothers, and the elderly.Children (15% of children have had at least one episode of syncope before adolescence.) Causes: Missed meal Heat Dehydration Crying Exertional activity

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Syncope Elderly:

Postural changesDefecationCoughingOrthostatic hypotensionMedicationsDiseases: coronary heart disease, heart failure, diabetes,

renal insufficiency, chronic obstructive pulmonary diseaseMortality rate from syncope for patients age 60 and older

is 5 times higher than patients under 60.

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Signs and Symptoms of Pre-Syncope

PallorPupil dilationDiaphoresis: cold sweatExcitation of piloerector musclesWeakness, dizziness, vertigoNausea, tingling in toes and fingers**Yawning or sighingUsually occur several minutes before loss of consciousness. Table 5.1 pg 51 in book.

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Signs and Symptoms of Pre-Syncope

Vision changes – darkening, blurring, seeing spotsIncreased BPShortness of breathHeart palpitationsChest painSlow onsetDental professional may see the patient become pale.Place patient in Trendelenburg position**

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Signs and Symptoms of Syncope

Syncopal symptoms◦ Unconsciousness◦ Weak, slow pulse◦ Low heart rate◦ Pallor◦ Flaccid muscles**

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Treatment of Syncope Remove objects from oral cavity Position supine with feet elevated Open airway Assess circulation Loosen tight clothing Administer oxygen, 4-6L/minute Monitor vital signs

Treatment of Syncope If unconsciousness persists summon EMS

Bradycardia 0.6 mg atropine IM

Longer patient in syncope more likely seizure will occur

Once consciousness returns◦ Keep in supine position until patient feels well enough to be returned to upright

position and pulse returns to normal

Treatment of Syncope Once consciousness returns

◦ Suspend treatment for the day◦ Emergency contact should escort patient home as syncope can reoccur ◦ If neurocardiac syncope suspected contact EMS◦ Thoroughly document syncope episode in chart

Figure 5.2 Patient in appropriate position for treatment of syncope

Types of SyncopeCardiac syncopeNoncardiac syncopeNeurocardiac syncope

Preventing syncope in the dental office** Review medical history for past episodes of syncope. Help patient to relax and reduce anxiety; build a good client-provider rapport; low-stress environment. Patient’s who feel faint: recline dental chair to Trendelenburg position (head lower than legs)

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Treatment of Syncope Remove objects from oral cavity Position supine with feet elevated: presyncopal symptoms indicate a 50-70% decrease in blood flow to the brain.

Open airway Assess circulation Loosen tight clothing Administer oxygen, 4-6L/minute Monitor vital signs

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Treatment of Syncope If unconsciousness persists summon EMS (unconsciousness can last

between a few seconds to minutes). Longer patient in syncope more likely seizure will occur due to lack of

oxygen to the brain. Ammonia inhalants are no longer recommended for use due to severe

complications. Once consciousness returnsKeep in supine position until patient feels well enough

to be returned to upright position and pulse returns to normal

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Treatment of Post-Syncope** Once consciousness returns

Suspend treatment for the dayEmergency contact should escort patient home as

syncope can reoccur within the first 24 hours of the first episode.

If neurocardiac syncope suspected contact EMSThoroughly document syncope episode in chartAt the next dental appointment, the patient may

need anti-anxiety medications.The patient should be evaluated by a medical

doctor.

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Chapter 6SHOCK

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Shock Condition produced when the cardio-vascular pulmonary system fails to deliver enough oxygenated blood to body tissues to support metabolic needs Tissues use anaerobic (without air) metabolic processes Produces acidosis (increased acidity in the blood) and harmful toxins

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Stages of ShockInitialCompensatoryProgressiveRefractor

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Stages of Shock Initial – first stage◦Cells deprived of oxygen◦Inhibits ability to produce energy◦Cells not functioning properly◦Impacts body systems

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Stages of Shock Compensatory (2nd stage) – body performs physiological adaptations in an attempt to overcome shock◦ Increased respiration to increase oxygen to cells◦ Increased blood pressure to compensate for hypotension

(low blood pressure)◦ Reduced blood supply to peripheral organs to improve

blood supply to brain◦ Reduced blood flow to kidneys with resulting oliguria

(reduced urine output)

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Stages of Shock Progressive ( 3rd stage) – compensatory mechanisms begin to fail◦ If the problem causing shock is not treated, condition will worsen

◦Vital organs compromised and not functioning appropriately

◦Systolic hypotension (low BP)

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Stages of Shock Refractory (4th stage) – failure of vital organs

◦Irreversible◦Cell death and brain damage have occurred◦Death will occur in a few hours

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Types of Shock Hypovolemic Cardiogenic Distributive

◦Anaphylactic◦Septic◦Neurogenic

Obstructive

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Hypovolemic Shock Most common form. A state of decreased blood volume. Caused by inadequate venous return to the heart Etiologies:

◦ Hemorrhage or dehydration (vomiting or diarrhea)

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Hypovolemic Shock Initial symptoms:

◦Peripheral vasoconstriction causing an elevated diastolic BP

◦Increased heart rate◦Rapid, thready pulse◦Cool skin◦Reduced urine output◦Confusion

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Hypovolemic Shock Treatment

Stop the bleeding, diarrhea, or vomiting that is causing the shock.

Supine positionCall EMSABC’s of CPRMonitor vital signsAdminister oxygen 4-6L/minuteIV fluids to restore circulating blood volume

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Cardiogenic Shock Reduction in perfusion due to decreased cardiac output. Heart fails to pump enough blood to supply oxygen to the peripheral tissues and body organs.

Etiologies (Can be caused by) damage to the heart due to….◦ MI (heart attacks)◦ Cardiac arrhythmias◦ Cardiac dysfunction

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Cardiogenic Shock Signs and symptoms

Reduction in BP with systolic below 90 mmHg Fast, weak pulse Cold, clammy skin Cyanosis: blue or purple color of skin due to the

tissues receiving less oxygen Non-specific chest pain Shortness of breath Reduced urine output and confusion Mental confusion

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Cardiogenic Shock Treatment

Supine position (Face up)Contact EMSMonitor vital signsAdminister oxygen using a non-re-

breather maskNeeds IV fluids: treatment provided in

ERCardiac medications needed: beta

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Distributive Shock Vasogenic shock (another name for distributive shock)◦3 types: result from vasodilation and abnormal distribution of fluids in the circulatory system.◦Anaphylactic◦Septic ◦Neurogenic

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Anaphylactic Shock Sudden, massive vasodilation and circulatory collapse following exposure to an allergen

Will be discussed in detail later in Allergy chapter

Treatments: epinephrine, histamine blockers, or corticosteroids.

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Septic Shock

Also called: Vasodilatory shock Bacteria (particularly gram-negative bacilli) invades bloodstream and causes an inflammatory response to try to rid itself of the invader Result of a severe infection. Can cause multiple organ failure and death.

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Septic Shock Signs and symptoms

Fever, vasodilation (widening of blood vessels)Increased cardiac outputTissue edema (swelling)Pink, warm skinRestlessnessTachycardia (rapid heart rate)ThirstEventual respiratory failureVasodilation causes the patient to appear pink &

warm, which differs from all other forms of shock

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Septic Shock Signs and symptoms

Can cause microthrombi formation (small blood clots)Often fatal and cause multiple organ failure. Usually seen in elderly individuals, individuals with

poor nutritional status, neonates (babies), critically ill, and immunocompromised patients

hypotension, restlessness, anxiety, tachycardia, thirst, respiratory failure.

Treatment: fluids, antimicrobial therapy, possible surgery to reduce or eliminate the infection.

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Neurogenic Shock Loss of sympathetic nerve activity (activates the fight or flight response) from brain’s vasomotor center, which regulates blood pressure, due to an emotional trauma, disease, drug, or traumatic injury to brain or spinal cord

Loss of sympathetic nerve activity causes peripheral dilation (expansion of blood vessels) leading to reduction in venous return, thus causing decreased cardiac output with hypotension (low blood pressure)

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Neurogenic Shock

Signs & symptoms◦Hypotension (low blood pressure)◦Bradycardia (low heart rate)◦Brain and kidneys at risk of failure

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Neurogenic Shock Treatment

◦Position supine◦Contact EMS◦Monitor vital signs◦Needs drug therapy to restore cardiac output: like dopamine to promote vasoconstriction, and epinephrine to restore blood pressure and cardiac output.

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Obstructive Shock Results from indirect heart pump failure Leads to decreased cardiac function and reduced circulation Etiologies

arterial stenosis: narrowing of an arterypulmonary embolism: blockage of the main artery of

the lung or a branch of the lung by a substance that has traveled through the blood stream.

cardiac tamponade: when fluid fills up the sac around the heart faster than the sac can stretch.

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Obstructive Shock Symptoms

◦ Severe Hypotension: low blood pressure ◦Dyspnea: shortness of breath

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Obstructive Shock Treatment

◦Position supine◦Contact EMS◦Monitor vital signs◦Needs IV fluids◦Relieving source of obstruction essential, surgical intervention often required

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Hyperventilation A condition whereby rapid, deep breathing occurs, thus

eliminating more carbon dioxide than is produced Normal respiration rate for an adult: 12 – 20 RPM Rarely exceeds 22 RPM A person hyperventilating might have a RR: 22-40 Affects 6–15% of population More common in females age 30 – 40

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Hyperventilation Optimal pH 7.4 – slightly alkaline Hyperventilation – pH 7.5 or higher This minor change can have significant physiological effects

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Hyperventilation Common when individuals are exposed to high altitudes, are pregnant,

take CNS stimulants, experience aspirin toxicity, or are extremely anxious CNS drugs- Central nervous system stimulatory drugs, such as:

antidepressants, hallucinogens, marijuana, lidocaine, benzocaine, codeine, hydrocodone, morphine, diazepam.

Lack of carbon dioxide in the arterial blood system (hypocapnia) leads to respiratory alkalosis (increase in the pH of blood) and cerebral vasoconstriction.

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Signs and Symptoms Table 7.1 pg 67

Hypocalcemia – reduction in calcium levels in blood Symptoms mimic pulmonary embolism – blockage of pulmonary artery – can be fatal – patients often die within 2 hours of onset

Signs and Symptoms Most common symptoms: Abnormally prolonged

rapid and deep respirations Decrease in carbon dioxide causes vasoconstriction of

blood vessels leading to decreased cardiac output – can cause palpitations and chest pain

Impairment of problem solving abilities, motor coordination, balance, and perceptual tasks due to lack of oxygen to the brain.

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Figure 7.1 Lorazepam

Treatment Operator remain calm Place patient in position of their choice – usually upright Loosen tight clothing in neck region Work with patient to control rate of respirations

Have patient count to 10 in one breathBreathe through pursed lips or noseNO MORE PAPER BAGS: can cause suffocation and

cardiac arrest.

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Treatment Monitor vital signs DO NOT administer oxygen-it can make the condition worse. If symptoms do not improve administer benzodiazepine (Lorazepam 1-2 mg IM or Diazepam 2-5 mg IM) If symptoms do not improve contact EMS

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Seizure Temporary episode of behavior alteration due to massive abnormal electrical discharges in one or more areas of the brain.

Changes in consciousness-involuntary contractions of the muscles.**

Epilepsy or seizure disorder: condition where a person has recurrent seizures and convulsions.**

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Seizure Can be recorded on EEG May be accompanied by convulsions or other neurological, sensory, or emotional changes

Can be caused by systemic distress – isolated non-recurrent attacks◦ Hypoxia◦ Hypoglycemia◦ Seizures

Preventing Seizure Activity

Medical History: identifying patients with a past history of seizures or convulsions.**

Evaluate medications the patient is taking to control seizures and if the patient has taken their seizure medications.**

Schedule shorter appointments early in the day.** DO NOT use Nitrous Oxide on seizure patients**

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Epilepsy•Common disorder•2 million in the United States•Seizures most common are neurological disorders in pediatrics

Epilepsy•Initial seizures in adults usually due to trauma, disease, or stroke.•A Seizure is not a disease, but a symptom of CNS dysfunction•Seizures not usually life-threatening•Rare cases if seizure continues without stopping or without a recovery period (status epilepticus) it becomes a true medical emergency and appropriate therapy is needed to prevent death.

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Etiology of Seizures Cellular level – several theories

◦ Alterations in cell membrane permeability

◦ Decreased inhibition of cortical or thalamic neuronal activity

◦ Changes in cell structure that alter cellular excitability

◦ Imbalances in neurotransmitters

Classification of Seizures Two broad categories

Primary/unprovoked or idiopathic Usually part of epileptic syndrome 65% of seizures are of this kind Genetic tendency Usually require daily anti-seizure medication

Secondary/provoked or acute symptomatic 35% of seizures are of this kind

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Seizures in Dental Setting

Several potential etiologiesHypoglycemiaHypoxia – secondary to syncopeLocal anesthetic toxicityEpilepsyHypoglycemia, hypoxia and local anesthetic toxicity

can be prevented by appropriate patient management and taking a thorough medical history.

Reducing stress will help prevent seizures caused by epilepsy.

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Types of Seizures Partial seizures

◦ Simple partial with no loss of consciousness◦ Jacksonian◦ Sensory

◦ Complex partial

Partial (Focal/Local) Seizures

Most common type of seizure among newly diagnosed adults. Come from a localized area in the brain, but can spread to the entire brain causing a generalized seizure.

Signs and symptoms depend on the area affected in the brain. Two major types of partial seizures: simple and complex.

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Simple Partial Seizures Symptoms

◦ Foul smells◦ Aura

◦ Visual – occipital lobe◦ Auditory – temporal lobe◦ Amnesia often follows

◦ Auras now considered to be a simple partial seizure with impending complex or generalized seizure

Simple Partial Seizures

Consist of motor, sensory, or psychomotor changes with NO loss of consciousness.

Symptoms: illusions, déjà vu, flashing lights, hallucinations, tingling and creeping sensations, vertigo, sounds, and foul smells or auras.

Symptoms may reflect the area of the brain activity: visual-occipital lobe; auditory-temporal lobe; olfactory.

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Simple Partial Seizures: AurasSymptoms:

Aura – sensory symptom occurring at onset of seizure.

Signals the beginning of abnormal changes in a focal area of the brain.

Typical auras include strong smells, nausea, mood changes, unusual tastes, visual disturbances lasting

only a few seconds.Amnesia often followsAuras now considered to be a simple partial seizure which serve as a warning sign of impending complex or

generalized seizure.

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Complex Partial Seizures

Signs and symptoms Lose contact with surroundings – a few seconds to 20 minutesAutomatisms – repetitive, non-purposeful activity (lip smacking, grimacing, patting, wandering in circle unintelligible speech)At the end of motor activity – mental confusion or fear

Generalized Seizures: Tonic-Clonic (GTCS) or Grand Mal Seizures

Most common type of seizure disorder. Occurs equally in males and females, and at any age. Most GTCS occur by puberty. Specific sequence of events from the warning phase to recovery, not all patients experience all events.

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Phases of GTCS Generalized Tonic-Clonic Seizures (GTCS)

◦ Specific sequence◦ Aura◦ Preictal Phase◦ Ictal

◦ Tonic phase◦ Hypertonic phase◦ Clonic phase

◦ Postseizure or postictal phase

Four stages of GTCS: first stage is aura

Aura or prodromal phase. (also discussed under simple partial seizures)

Considered to be a simple partial seizure, an aura is a sensation that precedes seizure activity.

Some people experience changes in emotional state, such as extreme anxiety or depression.

Most have the same aura experience prior to a seizure.The amnesic effect of seizures causes the person to not

remember experiencing an aura.

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Preictal Phase: second stage Occurs soon after aura Patient loses consciousness May fall if standing – the most common cause of seizure related injuries.

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Ictal Phase Tonic phase

◦ Muscles have sustained contraction – patient appears rigid◦ Produces loud cry – epileptic cry or crowing◦ Dyspnea and cyanosis due to contraction of respiratory muscles

Hypertonic Phase◦ Extreme muscle rigidity

Ictal Phase continue Clonic phase

◦ Muscular contractions and relaxation◦ Clenched jaw◦ Saliva + air = froth at mouth◦ Blood from biting tongue or soft tissues◦ 2-5 minutes – gradually slow with final flexor jerk

Post-Ictal Phase Movement stopped Patient remains unconscious CNS, CVS, and respiratory system depression CNS and respiratory may lead to airway obstruction – time when death is most likely

Post-Ictal Phase Muscle relaxation – urinary or fecal incontinence

Patient awakens – confused, fatigued, wanting to sleep, amnesia

Lasts for minutes to several hours

Fourth Ictal Phase Postseizure or postictal phase:

Movement stopped, pt remains unconscious.

When seizure stops, depression occurs in the central nervous system, cardiovascular, and respiratory systems, related to how severe the seizure was.

Depression of the CNS and respiratory systems may lead to airway obstruction the time when death is most likely to occur.

Muscle relaxation after the first minutes after the seizure causing urinary and/or fecal incontinence,

Patient awakens – confused, fatigued, wanting to sleep, amnesia, Lasts for minutes to several hours, close observation essential to

protect the airway.

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Treatment of Seizures Primary task in the dental office is to try

and prevent injury to the patient having the seizure.

Specific steps should be followed depending on the type of seizure.

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Treatment of GTCS Seizures

Primary task Cease dental treatment Remove instruments from mouth Move equipment out of the way Loosen tight clothing Place in supine position

Treatment of GTCS Seizures

Leave patient in dental chair Contact EMS ABC’s of CPR Monitor vital signs Gently restrain to prevent injury

Treatment of GTCS in the dental office

If the patient is in the chair, do not move patient, but lower the chair and help prevent patient from falling by positioning one person at the head and one person at the foot of the chair.

Call EMS if the seizure last longer than 3 minutes or the patient becomes cyanotic. Give oxygen 6-8 L/min through a non-rebreather mask. CABs of life support provided if needed, vitals should be monitored. Pt should be gently restrained to prevent injury. Do NOT place anything into the patient’s mouth.

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Status Epilepticus Status epilepticus or continuous GTCS or repetitive recurrence of any type of

seizure without recovery between episodes. Life-threatening situation May persist for hours or days and is the major cause of mortality related to

seizure disorders. Temperature may rise to 106° F, tachycardia and dysrhythmias may occur, and

BP elevated to 200/150. Uninterrupted grand mal status may continue until death occurs as a result of

cardiac arrest, irreversible brain damage due to lack of oxygen, or a significant decrease in blood glucose levels.

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Status Epilepticus Incidence of grand mal status has decreased due to effective antiseizure medications.

If a tonic-clonic seizure does not stop after 5 minutes, the use of anticonvulsant drugs may be necessary-call EMS.

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Absence or Petit Mal Seizures (nonconvulsive)

Neither generally pose a problem during dental treatment. If one of these seizures occurs, stop dental treatment, protect the pts airway.

Remove all instruments from the pts mouth. Monitor vital signs. Treatment can continue at the end of the seizure if the pt has no ill effects.

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Prevention for Known Seizure Patients

Discuss with patients who respond positively to seizures on their med hx: Recent illnesses, stress, hormone

fluctuations, fatigue Recent hx of head trauma Recent hx of fever, headache, stiff neck Alcohol or substance abuse

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General physical condition, including depression

Taking prescribed meds on schedule

Info about seizure history

Alteration or loss of consciousness

Postictal systems such as confusion or amnesia

Prevention strategies in the dental office

Clinician may wish to postpone dental tx if there are risk factors indicated in the patient’s medical hx.

Blood glucose levels, fatigue, and anxiety are common triggers for seizures in poorly controlled cases.

Patient’s doctor may need to be consulted.

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Best time to tx seizure pts: early morning appts, after pts have eaten and within a few hours of taking antiseizure meds.**

Irritability is often a symptom that a seizure is coming.

Cerebrovascular Accident (CVA) AKA stroke Abnormal condition of the brain Leads to cell death Second leading cause of death world wide US

◦ third leading cause of death and disability

Risk Factors for CVA Age African Americans Atrial fibrillation

◦ 2 million Americans◦ Two atria quiver◦ Heart pumps blood inefficiently resulting in pooling of blood –

leads to thrombi◦ Increases risk of CVA five fold

Risk Factors for CVA Oral contraceptives Menopause due to estrogen changes Diabetics Familial history of CVA Carotid Bruit – abnormal sound in carotid artery

Transient Ischemic Attacks

Brief episodes of neurological dysfunction Last less than one hour 200,000 – 500,000 suffer from TIAs annually 10% of all strokes preceded by TIA CVA often occur within first 4 days of TIA

Ischemic CVA Blockage Thrombus or embolus 85% CVAs – 60% thrombotic; 40% embolic Core - central zone of ischemic tissue Penumbra – surrounding tissue receiving diminished blood supply

◦ Potentially salvageable if blood supply restored quickly

Hemorrhagic CVA Rupture 15% Factors

Types of Hemorrhagic CVA

IntracerebralSubarachnoid Mortality Pressure that is causing damage gradually diminishes and brain regains some of its former function

Intracerebral CVA Twice as common Occurs when defective artery within the brain bursts Surrounding tissue fills with blood Blood places pressure on adjacent tissues Due to ruptured artery other areas of brain ischemic leading to additional damage

Subarachnoid CVA Occurs when blood vessel on surface of brain ruptures and bleeds into subarachnoid space

Blood places pressure on cerebellum causing pressure and damage to brain cells

Signs and Symptoms of Ischemic CVA

May stop and start again as stroke progresses Severity and location Altered level of consciousness Pupils unequal and dilated Confusion Dizziness Change in balance or coordination (ataxia) Vision changes – loss of half the visual field

Signs and Symptoms of Ischemic CVA

Deviation of tongue Difficulty swallowing (dysphagia) Speech changes

◦Poorly articulated speech (dysarthria)◦ Impairment of speech (dysphasia)◦ Inability to understand spoken word◦Inability to speak at all (aphasia)

Signs and Symptoms of Ischemic CVA Drooling Weakness, numbness, or tingling in one side of face Facial droop Numbness or tingling in arm or leg or both on one side of body (hemiparesis)

Nausea or vomiting

Signs and Symptoms of Hemorrhagic CVA

Onset abrupt and rapid Severe headache Increased BP Subarachnoid CVA – neck pain or stiffness Inability to stand or walk Papillary malalignment Nausea or vomiting Altered level of consciousness

Stroke Scales Cincinnati Pre-Hospital Stroke Scale (CPSS) Looking for facial palsy, arm motor weakness, dysarthria

◦ Ask patient to smile – observe for weakness on one side of face◦ Ask patient to hold out both arms palm up and eyes closed for

10 seconds – observe for weakness in one arm

Stroke Scales◦ Ask patient to repeat simple sentence – “The sky is blue in Cincinnati.”

– observe for difficulty in speech

◦ If any of the 3 components found to be abnormal then assume CVA

Treatment Contact EMS immediately Position semi-supine BLS – check airway, breathing, and circulation

Administer O2 4-6L/min Test glucose levels to rule out hypoglycemia

Treatment Monitor vital signs Transport to ED as soon as possible Aspirin for ischemic CVA reduces death and recurrence rates Aspirin for intracranial hemorrhage CVA patients also improved outcomes – however not recommended

Treatment In hospital

◦ CT scan to determine etiology◦ Hemorrhagic – probably surgery◦ Ischemic – < 3 hours onset of symptoms then IV thrombolytic therapy with

altaplase (r-tPa) – removes thrombus or embolus to restore blood flow◦ Ineffective after 3 hours◦ Contraindicated for hemorrhagic CVA

Click to add titleAn epileptic cry caused by air rushing from the lungs may

occur during which stage of a grand mal seizure?a. Preictalb. Convulsivec. Postictald. Characteristic of hysterical seizure

B

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