Unconsciousness, Vasodepressor Syncope and Postural Hypotension

Cecille Mae Uy Deomano, DMD

UNCONSCIOUSNESS

Definition of Terms
Unconsciousness lack of response to sensory stimulation Syncope/ Faint- transient loss of consciousness caused by reversible disturbances in cerebral function (patient regains consciousness within 30 minutes) Anoxia absence or lack of oxygen Hypoxia - low oxygen content

Possible Causes
Cause Frequency

Vasodepressor syncope
Drug administration/ ingestion Orthostatic Hypotension

Most Common
Common Less Common

Epilepsy
Hypoglycemic reaction

Less Common
Less Common

Acute adrenal insufficiency

Acute allergic reaction Acute myocardial infarction

Rare
Rare Rare

Cerebrovascular accident
Hyperglycemic reaction

Rare
Rare

Hyperventilation

Rare

Predisposing Factors
Stress Impaired physical status Administration or ingestion of drugs (analgesics, anti-anxiety agents, antibiotics)

Clinical Manifestation
Does not respond to sensory stimulation Has lost protective reflexes Inability to maintain patent airway

Pathophysiology
Mechanism Clinical Example

Inadequate delivery of blood or Acute adrenal insufficiency oxygen to the brain Hypotension Orthostatic hypotension Vasodepressor syncope Systemic or local metabolic Acute allergic reaction deficiencies Drug ingestion Direct or reflex effects on nervous system
Psychic mechanisms

Cerebrovascular accident Convulsive episodes

Emotional disturbance Hyperventilation Vasodepressor syncope

Inadequate Cerebral Circulation

Dilation of peripheral arterioles Failure of normal peripheral vasoconstrictor activity Sharp drop in cardiac output Constriction of cerebral vessels (hyperventilation) Occlusion or narrowing of the internal carotid artery Life threatening ventricular dysrhythmias

Oxygen Deprivation
Hypopharyngeal obstruction by the base of the relaxed tongue

Complete or Partial airway obstruction Loss of Consciousness

Oxygen Consumption of the Brain

Human brain uses approximately 20% of the total oxygen and 65% of the total glucose the body consumes 20% of the total blood circulation must reach the brain per minute

Prevention
Pretreatment medical and dental evaluation of the patient Use of conscious sedation techniques Use supine position or slightly upright position in treating the patient

Management
Recognition of the unconsciousness
Shake the patients shoulder and shout loudly: Are you alright? Application of peripheral pain (pinch the suprascapular region)

Terminate dental procedure Summon help

Management
Position the victim
Supine position with the brain at the same level as the heart and feet elevated slightly (10-15 deg) Trendelenburg position is discouraged

ABCs of Emergency Medicine

A- airway B- breathing C- Circulation

Assess and Open the Airway

Head tilt- chin lift maneuver

Assess and Open the Airway

Jaw-thrust technique

Assess airway patency and Breathing

Look, listen and feel technique

Determination of Airway Patency and Breathing

Clinical signs
Feel Hear See Feel Hear See Feel Hear See (erratic and heaving) Feel Hear See

Diagnosis
Airway patent; patient is breathing Airway patent; patient is breathing Patient attempting to breathe but airway is still obstructed Respiratory arrest

Management
Maintain airway

Maintain airway

Repeat head tilt, if necessary, use jaw thrust technique Begin artificial ventilation

Artificial Ventilation
Exhaled air ventilation Atmospheric air ventilation Oxygen rich ventilation

Exhaled Air Ventilation

Mouth to Mouth Mouth to Nose

First cycle: 2 full breaths In adults: 10-12 breaths per minute In children: 20 breaths per minute

Adequacy of ventilatory efforts

Feeling the escape of air as the victim passively exhales Seeing the rise and fall of the victims chest

Atmospheric Air Ventilation

Delivery of 21% oxygen Use of Bag-valve-mask

Airway Adjuncts
relieve upper airway obstruction caused by the tongue by lifting the tongue from the back of the hypopharynx

Oxygen rich Ventilation

Delivers greater than 21% of oxygen E cylinder of oxygen

Assess Circulation
Monitoring heart rate and blood pressure Sites for heart rate monitoring:
Brachial and radial arteries in the arm Carotid artery in the neck

Assess Circulation
If a pulse is present, the rescuer should continue with steps 4-6 (maintaining postion, airway and breathing) If a palpable pulse is not present within 10 seconds, initial chest compressions must be done

Management of Unconsciousness
Recognition of the Problem Discontinue Dental Treatment Activate Office Emergency Team P- Position the patient in supine position with feet elevated A B C

Activate Emergency medical service if recovery is not immediate

D- Provide Definitive management as needed

VASODEPRESSOR SYNCOPE

Predisposing Factors
Psychogenic Nonpsychogenic

Fright Anxiety Emotional stress Receipt of unwelcome new Pain Sight of blood

Erect sitting or standing posture Hunger from dieting Exhaustion Poor physical condition Hot, humid, crowded environment Male gender Age between 16 and 35 years

Prevention
Proper positioning
place patient in supine or semi-supine position

Anxiety relief
Do thorough patient evaluation to be able to modify treatment Psychosedation

Manifestations
Presyncope
Feeling of warmth Loss of color Heavy perspiration Reports of feeling bad or faint Nausea Slightly lower BP Tachycardia

Manifestations
Syncope
Differences in breathing pattern Dilation of pupil Convulsive movements and muscle twitching Bradycardia, HR less than 50 bpm Pulse is weak and thready

Manifestations
Postsyncope
Rapid recovery is expected after proper patient positioning Patient may exhibit pallor, nausea, weakness, and sweating Patient may also exhibit confusion and disorientation HR returns to baseline

Pathophysiology
Stress Release of catecholamines (epi and norepinephrine)

Increase blood flow to muscular tissues Peripheral pooling of blood Decrease in blood volume Decrease in arterial blood pressure Decrease in cerebral blood flow (<30ml/100g of brain tissues)
Syncope

Management
P Position A Airway B Breathing C Circulation D Definitive measures

Definitive Care
Administration of oxygen Monitoring of vital signs Additional procedures
Loosening of binding clothes Use of a respiratory stimulant (ammonia) Cold towel may be placed if patient is shivering If bradycardia persists, atropine may be administered

Postpone further dental treatments

POSTURAL HYPOTENSION

Definition
Disorder of the autonomic nervous system in which syncope occurs when the patient assumes an upright position Drop in the systolic pressure of 30mmHg or greater or a 10mmHg or greater fall in diastolic pressure Result of a failure of the baroreceptor reflex mediated increase in peripheral resistance

Predisposing Factors
Administration and ingestion of drugs
(antihypertensives, psychotherapeutics, opioids, histamine blockers, nitrous oxide, etc)

Prolonged period of recumbency or convalescence Inadequate postural reflex Late- stage pregnancy Advanced age Venous defects in the legs

Prevention
Thorough history taking Physical evaluation (BP, HR, RR) Dental therapy considerations
Elevate the chair slowly Caution patient before standing up Stand nearby as the patient stands after treatment

Clinical Manifestations
No prodromal signs and symptoms Patient may lose consciousness rapidly or may merely become light headed Patient may develop blurred vision Drop in BP but same HR

Normal Regulatory Mechanisms

Feet 120mmHg 120mmHg 12 20 Head

Supine position: equal BP

Semiupright position: pressure decrease by 2mmHg/ in the individual remains above the heart level
Trendelenberg position: pressure increase by 2mmHg/in the individual remains below the heart level

30

20

Normal Regulatory Mechanisms

Reflex arteriolar constriction and increase in HR through baroreceptors in the carotid sinus and aortic arch Reflex venous constriction mediated intrinsically and sympathetically Activation of venous pump Reflex increase in respiration Release of neurohormone substances

CV reaction to postural change

Change Normal (at 60sec) after sudden elevation Systolic BP Baseline or +/10mmHg Diastolic BP Increase of 1020mmHg Heart rate 5-20 beats per minute above baseline Postural Hypotension Decrease > 25mmHg Decrease >10mmHg Baseline or higher (>30 beats per minute)

Management
P Position A Airway B Breathing C Circulation D Definitive measures

Definitive Care
Administration of oxygen Monitoring of vital signs Subsequent management
Change from supine to upright must be slowly with sufficient time for accommodation Help the patient rise from the chair Allow the patient to recover fully before leaving the office

THANK YOU!