Medical Emergencies

In Dental Practice

Dr. Hassan Abdel-Ghany

.Lecturer of OMFS, Cairo Uni
Hassan_ao@hotmail.com
!PREVENTION

Attitude and environment

Usually a clue in the history
Airway protection
Drills roles, training, contact numbers
Do not work alone
THE ABCDE APPROACH

A Airway
B Breathing
C Circulation
D Disability
E Exposure
AIRWAY

Finger sweep
Suction
Head tilt/Chin lift
AIRWAY

Finger sweep
Suction
Head tilt/Chin lift
Jaw thrust- injury or flexion deformity
Head Tilt/Chin Lift
-Jaw thrust
BREATHING

Look, listen and feel

CIRCULATION

Central pulse e.g. carotid for the

competent/experienced practitioner
DISABILITY

Neurological (conscious status) e.g. Post head

injury/seizure

A lertness
V ocal stimuli response
P ain response
U nresponsive
EXPOSURE

For examination of rash/application

of defibrillator paddles (AED: Automated External defibrillator)
COLLAPSE OF UNKNOWN CAUSE

Lie patient flat, raise legs most recover

Maintain airway, give oxygen
Check breathing - agonal gasps
If not breathing/abnormal breathing (no pulse) =
cardiac arrest
No signs of life
If normal breathing give sc/im glucagon 1mg
Get help at an early stage
CARDIAC ARREST

Main cause arrhythmia (VF)

AED
REMEMBER RATIOS OF CPR

No rescue breaths

compressions to 2 ventilations in adults 30

Importance of early defibrillation

CPR IN PREGNANCY

Left lateral position

EMERGENC
Y DRUGS
USED IN
DENTISTRY
DRUGS FOR EMERGENCY DRUG BOX
Adrenaline (Epinephrine) 1 in 1000
Aspirin (300mg)
Glucagon (1mg) (Glucose)
GTN tabs/sprays
Oxygen
Salbutamol inhaler
Midazolam buccal liquid or Midazolam injection
solution via buccal or nasal route (10mg)
DRUGS FOR EMERGENCY DRUG BOX
Adrenaline (Epinephrine) 1 in 1000
DRUGS FOR EMERGENCY DRUG BOX

Aspirin (300mg)
DRUGS FOR EMERGENCY DRUG BOX

Glucagon (1mg) (Glucose)

DRUGS FOR EMERGENCY DRUG BOX

GTN IV/tabs/patches/sprays
DRUGS FOR EMERGENCY DRUG BOX

Oxygen
DRUGS FOR EMERGENCY DRUG BOX

Salbutamol inhaler
DRUGS FOR EMERGENCY DRUG BOX

Midazolam buccal liquid or Midazolam injection

solution via buccal or nasal route (10mg)
POSSIBLE ROUTES OF DRUG ADMINISTRATION

Oral
Sublingual
Subcutaneous
Intramuscular
Inhalation
Rectal
Intravenous (only if experienced)
Deltoid
 Specific Medical
Emergencies In Dentistry

Hypersensitivity
Chest discomfort
Respiratory difficulty
Altered consciousness
Metabolic problems
 Hypersensitivity
Reactions
Type I:
- immediate, acute and life-
threatening
- mediated primarily by IgE
- previous exposure history
 Hypersensitivity
Reactions
Skin signs:
- erythema, urticaria, pruritis,
angioedema
Respiratory tract signs:
- wheezing, mild dyspnea
- stridor, moderate to severe dyspnea
 Hypersensitivity
Reactions
Manifestation Management

1. Stop all drugs that currently

Delayed onset skin signs: use
Erythema, urticaria, pruritis, 2. IM or IV Allermin/CTM or
angioedema Benadryl p.o.
3. Prescribe antihistamine
1. Stop all drugs that currently
use
2. SC, IM or IV Epinephrine
(1:1000) 0.3ml, q5m if S & S
Immediate onset skin signs: progress
Erythema, urticaria, pruritis,
3. IM or IV Allermin/CTM or
angioedema
Benadryl p.o.
4. Monitor vital signs
5. OBS for 1 hr and prescribe
antihistamine
Manifestation Management
1. Stop all drugs that currently
use
2. In sitting position and give O2
Respiratory signs (wheezing, mild
dyspnea) with or without skin 3. Prescribe epinephrine and
signs antihistamine
4. Steam inhalation with
bronchodilator (Atroven +
Berotec or Ventolin)

Stridorous breathing (crowing

sound), moderate~severe Same as above and prepare to ER
dyspnea

Epinephrin Nasal cannula

e
Manifestation Management

1. Stop all drugs that currently

2.
Anaphylaxis (with or without skin
signs): malaise, wheezing,
3.
moderate~severe dyspnea,
stridor, cyanosis, total airway
obstruction, nausea & vomiting,
abdominal cramps, urinary 4.
incontinence, tachycardia,
hypotension, cardiac dysrhythmia, 5.
cardiac arrest
6.
use
Put the pt in supine position
on back board and give O2
Administer
epinephrine/antihistamine as
above
Monitor vital signs and
prepare for BLS
Steam inhalation with
bronchodilator (Atroven +
Berotec or Ventolin)
Consider if cricothyrotomy if
laryngospasm cannot relieved
Differential Diagnosis of
Acute Chest Pain: Common
Causes

Cardiovascular: angina pectoris, MI

Gastrointestinal: dyspepsia (heart burn),
hiatal hernia, reflux esophigitis, gastric
ulcer
Musculoskeletal: intercostal muscle
spasm
Psychologic: hyperventilation
Differential Diagnosis of
Acute Chest Pain: Uncommon
Causes

Cardiovascular: pericarditis, dissecting

aneurysm
Respiratory: pulmonary embolism,
pleuritis, tracheobronchitis,
mediastinitis, pneumothorax
Gastrointestinal: esophageal rupture,
achalasia
Musculoskeletal: chostochondritis
Psychologic: psychogenic chest pain
 Chest Discomfort:
--- AMI or angina pectoris
Pain pattern
- Characteristics: squeezing, bursting, pressing,
burning or choking
- Location: substernum
- Refer pain: Lt shoulder, arm, neck
or mandible
- Associated with exertion, anxiety
- Relieved by vasodilator (ex. NTG) or
rest
- May accompanied by dyspnea, nausea& vomiting
sensation,
palpitation
1. Terminate all procedures
Angina pectori
2. Semi-reclined position
3. Sublingual NTG
4. O2
5. Check vital signs

Discomfort Still discomfort after

relieved 3min

6. Assume angina pectoris was Give 2nd NTG

present
7. Slowly taper O2 over 5min
8. Modify dental treatment Still discomfort after
3min

Give 3rd NTG

Still discomfort after

3min
NTG
0.6mg/tab
 10. Assume myocardial infarction in
progress
11. On IV line
12. Prepare transport to ER

If highly suspected AMI

MONA: Morphine, Oxygen, NTG,

Aspirin
Respiratory Difficulty:
Asthma
Hyperventilation
Chronic obstructive pulmonary
disease (COPD)
Foreign body aspiration
Gastric contents aspiration
Manifestations of An
Acute Asthmatic Episode:

Mild to moderate
- wheezing
- dyspnea
- tachycardia
- coughing
- anxiety
Manifestations of An
Acute Asthmatic Episode:
Severe
- intense dyspnea with flaring of nostrils &
use of accessory muscle
- cyanosis of mucous membrane & nailbeds
- minimal breathing sound on auscultation
- flushing
- extreme anxiety
- mental confusion
- perspiration
 Asthma
1. Terminate all procedures
2. Fully sitting position
3. Bronchodilators
(Atrovent/Berotec)
4. O2
5. Check vital signs

S&S Signs & symptoms

relieved continue

6. Monitor of recovery 6. Give Epi 0.3ml of 1:

state 1,000 IM
7. Consult physician or SQ
7. Build up IV line
8. Monitor vital signs

S & S not
relieved

9. Prepare to ER
10. Add steroid therapy
Manifestations of
Hyperventilation
Syndrome:

Neurologic
- dizziness
- tingling or numbness of fingers, toes
or lips
- syncope
Respiratory
- increased rate & depth of breaths
- SOB
- chest pain
- xerostomia
Manifestations of
Hyperventilation
Syndrome:

Cardiac
- palpitations
- tachycardia
Musculoskeletal
- myalgia
- muscle spasm
- tremor
- tetany
Psychologic
- extreme anxiety
Management of
Hyperventilation
Syndrome:

Terminate all procedures

On fully upright position
Verbally calm patient
Breath CO2-enriched air
Add Valium 10mg IM or IV; Dormicum
5mg IM or IV
Monitor vital signs
 Anxiety Increased
cathecholamine
release
Decreased peripheral
vascular resistance

Pooling of blood
periphery

Decreased ABP
Reflex vagally mediated
Compensatory mechanisms cause
bradycardia, nausea,
increased HR, feeling of warmth,
weakness & hypotension
pallor, perspiration, rapid breathing

Decompensation
occur
Reduced Lightheadness,
cerebral blood syncope
flow (if prolong)

Seizure
Vasovagal syncope activity
 Vasovagal syncop
Prodrome:
Terminate all procedures
Supine position with leg
elevation
Attempt to calm patient
Cool towel to forehead
Monitor vital signs

Syncopal episode: Atropine 1mg/amp

1. Terminate all procedures Used in severe
2. Supine position with leg bradycardia
Not exceed 2mg
elevation
3. Check breathing

If absent: If present:
4. Start BLS 4. Ammonia under nose
5. Prepare to ER 5. Monitor vital signs
6. Consider other 6. Plan anxiety control at next
cause visit
Manifestations of Seizure
Attack:

Isolated, brief seizure

- tonic-clonic movement of trunk &
extremities
- loss of consciousness
- vomiting
- airway obstruction
- loss of urinary & anal sphincter
control
Repeated or sustained seizure (status
epileptics)
 After seizure
attack

Patient unconscious Patient conscious

If sustained
1. Place on side and 1. Suction airway
suction airway 2. Monitor vital signs
2. Monitor vital signs 3. Administer O2
3. Initiate BLS 4. OBS for at least
4. Administer O2 1hr and consult
5. Prepare to ER physician

1. Diazepam 5mg/min IV
2. Dormicum 3mg/min IV
or IM
3. Dialantin 10~15mg/kg
IV
Manifestation of acute hypoglycemia

Mild Moderate Severe

Tachycardia
Hunger Perspiration Hypotension
Nausea Pallor Unconsciousne
Mood change Anxiety ss
Weakness Behavior seizures
change
 Hypoglycemia
Terminate all
procedures

Mild S & S: Moderate S & S: Severe S & S:

Administer oral 1. Administer oral 1. IV D50, 50ml or
glucose source glucose source glucagon 1mg
Monitor vital signs 2. Monitor vital signs 2. Prepare to ER
Consult physician 3. IV D50, 50ml or 3. Monitor vital signs
Intake before next glucagon 1mg 4. Give O2
visit 4. Consult physician
Manifestations of acute
adrenal insufficiency:

Weakness
Feeling of extreme fatigue
Confusion
Hypotension
Nausea
Abdominal pain
Myalgias
Partial or total loss of consciousness
Management of acute
adrenal insufficiency:

Terminate all procedures

Supine position with leg elevation
Administer hydrocortisone 100~200mg
or Decardron 5~10mg
Administer O2
Monitor vital signs
Set up IV line
Start BLS if indicated
Decardron 5mg Hydrocortisone
100mg
Manifestation and management of local anesthesia tox
Manifestations
Mild: talkativeness, anxiety, slurred
speech, confusion
Moderate: stuttering speech,
nystagmus, tremors, headache,
dizziness, blurred vision, drowsiness
Severe: seizure, cardiac dysrhythmia
or arrest
Management
Stop administer L.A.
Monitor vital signs
OBS in office for 1 hr
Stop administer L.A.
Monitor vital signs
Place in supine position
Administer O2
OBS in office for 1 hr
Place in supine position
If seizure attackseizure algorism
Institute BLS if necessary
Prepare to ER
 Suggested maximum dosage of local
anesthetics

Local anesthetics Maximum No.

2% Lidocaine with Epinephrine 10

Mepivacaine 6
CONCLUSIONS

The use of emergency drugs is safe when the

!diagnosis is correct
The drug kit should be checked regularly to ensure
that it is up to date
In a special care setting, the best approach is to
stick to basic principles
Thanks for Your
Attention !!!

hassan_ao@hotmail.com
hassan_ao@yahoo.com