Medical Emergencies in the

Dental Office
Tomas J. Barrios DDS
Associate Clinical Professor of
Oral & Maxillofacial Surgery,
St. Josephs Regional Medical Center,
Jersey City Medical Center
• Prevention & Preparation
• Syncope
• Hypoglycemia
• Epileptic episode
• Angina
• Myocardial infarct
• Anesthetic overdose
• Drug allergy anaphylaxis
• Asthma
 Prevention & Preparation

• BLS Certification doctors and staff

• ACLS certification : any type of sedation
techniques
• Emergency Kits
• Staff drills
 Emergency Kits
• Contents Vary
• Purchase from any
manufacturer
• Refill
Components of emergency kits
 Emergency drills
• Most important : Keep it
simple !
• Designate a specific task to
each staff member
1. Assistant : gets kit and assist
Dr.
2. Receptionist : calls 911 and
make sure EMS arrives ,
clears area for patients
3. Additional staff : go between,
records vitals,
event timing
 ABC of any emergency

• Supine position
• 100 % Oxygen
• Evaluate Airway, breathing , circulation
• Vitals
 Emergency management &
resuscitation plan
• Primary survey • Secondary survey
1. ABCDE 1. Head to toe by region
2. Purpose : Identify & exam
treat life threatening 2. Purpose : Identify &
problems treat life threatening
3. History problems
4. Resuscitation measures 3. History : data gathering
are instituted 4. System specific test
5. Re evaluation: repeat
surveys untill cause is
identified
6. Definitive care
 Vitals, Clinical signs and
symptoms of potential illness
 Tenets of primary survey
• Proceed rapidly
• Err on the side of aggressiveness
• When in doubt “do”
• Stay in sequence
• Know what to look for , recognize and treat
• Look for likely, treatable problems
• Make decisions based on direct examination
• Initiate only simple test and procedures
Generalized treatment protocol
 Documentation

• Brief history of the event

• Positive findings of primary & secondary
survey
• Treatment provided
• Time of important events
• Disposition
 Medical legal issues

• What if its not a patient in the office ?

• Death or Hospital transfer by EMS , is a

reportable event to the State Board
Syncope
Types of syncope
 Vasodepressor Syncope

• Most common medical emergency in

dentistry
• 30 % of adult population
• Accounts for 3% of ER visits
 Etiology

• Decreased cerebral blood flow (CBF)

 Differential diagnosis

Anxiety attacks
hyperventilation syndrome
MI
Hypoglycemia
Epilepsy
Hypotension
Clinical manifestation presyncopal

• Early • Late
Nausea Hypotension
Warmth Bradycardia
Perspiration Hyperpnea
loss of color Pupillary dilation
Baseline Blood press Peripheral coldness
Tachycardia Visual disturbance
Loss of consciousness
 Syncopal phase

• All secondary to decreased CBF

• Loss of consciousness
• Loss of postural tone
• Any syncope lasting > a few minutes can
induce seizures and cerebral ischemia
 Treatment
• Trendelenburg position
• Pregnant patient lateral decubitus
• Asses consciousness
• ABC
• 100 % oxygen
• Spirits of ammonia
• Vitals ( Bradycardia < 60 administer Atropine .5mg IV
1mg IM every 5 minutes until max dose of 3 mg
• EMS if loss of consciousness is > 5 min or if recovery is
> 20 min
 Postsyncope

• Evaluate discharge home with escort or

EMS
Dependent on recovery and Vitals
Recovery > 20 min
Underlying medical conditions
Hypotension
 Hypotension

• Following syncope it is the most common

cause of loss of consciousness in the
dental office
What affects perfusion ?
Causes of hypotension
 Orthostatic Hypotension

• Most common cause of hypotension in the

dental office
• It is Syncope when the patient is placed
quickly from a supine to upright position
( < CBF )
Why Most likely in elderly ?

• Aging decreases baroreflex mechanism

which impairs cardioacceleratory response
to preload reduction during upright
posture
• May be on medications
• Most susceptible
 Vasovagal Hypotension (syncope)

• Initiated by stressful physical ,

psychological or surgical stimuli ( coughing
pain, gagging )

• The impulses are transmitted directly to

the medulla in area closely related to the
nuclei of the vagus nerve
 Clinical sign and symptoms

• Bradycardia results from Vagal stimulation

and parasympathetic tone

• Vasodilation results from diminished

sympathetic tone
 Treatment

• Removing the initiating stimuli

• Trendelenburg position
• Oxygen
• Vitals
 Routine treatment for a patient
with hypotension and inadequate
perfusion
 Treatment
• Place in Trendelenburg position
• Oxygen
• Vitals
• ABC
• Evaluate BP
( if no BP monitor present , remember palpate
pulse, correlated to a systolic of: Radial 80 mm
Hg , Brachial 70 mm Hg , Carotid 60 m Hg )
• Administer: Phenylephrine spray 0.25-0.5 mg IV
2-3mg IM , Ephedrine 10-25 mg IV
• What if patients are receiving B-Blockers ?

Isoproterenol 0.2mg IV slowly at 1 min

interval and monitor patients response
Hypoglycemia
Diabetes
 Epidemiology

• Incidence 15.7 million or 5.9% of

population of U.S
• Incidence of undiagnosed 5.4 million or
34% of diabetic population
Why is glucose important ?
• Primary energy
substrate for all
functions
 Pathophysiology
• Type 1 IDDM : little or no insulin is secreted
uptake of glucose or conversion into glycogen in
the liver does not occur, therefore liver glucose
production is elevated. Gluconeogenesis
accelerates

• Type 2 NIIDM : Insulin resistance causes the

liver to continue glucose production and
prohibits glucose uptake by muscles
Clinical factors of diabetes
Type II NIDDM Meds
 Type I IDDM Meds

• Need to know or quick reference

 Monitoring

• Hemoglobin A1C
• Fructosamine
• Home monitoring
How are patients going to become
hypoglycemic ?
• Too much insulin
• Alcohol consumption
• Excessive exercise
• Missed delayed meals
• Reduced meals
• Medication error
• Other illness
 Symptoms
• Autonomic • Neuroglycopenic
1. Sweating 1. Dizziness
2. Trembling 2. Confusion
3. Palpitations 3. Difficulty speaking
4. Anxiety 4. Headache
5. Nausea 5. Inability to concentrate
6. Weakness
7. Blurred vision
Treatment
 Alternative TX

• Glucose tablets
• 4 teaspoons of sugar in water
• 5 oz of regular soft drink
• Orange juice

• Glucagon dosage : 0.5-1mg IM or IV

Seizures
 Seizures
• Manifestation of brain
dysfunction
• Excessive neuronal
cortical discharge
• Secondary to toxins,
drugs, cerebral
hypoxia, or metabolic
disturbances
 Prevention & preparation
• History
1. What type of seizure disorder do you have ?
2. Are you on any medications for the disorder ?
3. Are you taking the medications as prescribed ?
4. Have you had serum level of the medication done ? If
so when ?
5. When was your last seizure ?
6. What provokes it ?
7. Do you have an Aura ?
8. Where you hospitalized ?
9. How long was your seizure ?
 Treatment protocol
• Most seizures last < 2 min
• EMS activated
• Assure patient & staff safety
• Administer oxygen
• Manage airway
• Monitor vitals , pulse oxymetry
• Suction available
• If seizure is lasting > 2 minutes , establish IV,
administer Meds
 Benzodiazepine
• Diazepam • Midazolam
Adult : 5 to 10 mg 0.05 to 0.1 mg/kg IV
IV/IM 0.2 mg/kg IM ( Max
Pediatric : 0.2 to 0.5 10 mg)
mg/kg IV/IM
 Pharmacologic management

• EMS not arrived > 5 min

Adult : Dextrose 50 ml bolus of 50%
glucose
Pediatric : 2ml/kg 25% dextrose solution

• Evaluate airway maintenance

• Evaluate cardiac rhythm
 Postictal

• Lethargy
• Disorientation
• Apnea, obstructed airway
• Cardiac arrhythmias
• Evaluate patient injury
Chest pain
• Angina : Latin for spasmodic , choking or
suffocating pain
• Pectoris :Latin for chest
 Differential Diagnosis
• Angina
• Myocardial infarction
• Dyspepsia, GERD
• Musculoskeletal
• Pulmonary embolus
• Spontaneous pneumothorax
• Aortic dissection
• Esophageal rupture
• Panic disorder
 Relevant factors
• Onset : time, associated
event
• Location
• Radiation absence or site
• Type of pain: deep
visceral, superficial,
pleuritic
• Exacerbating or
alleviating factors
What occurs ?
• Increased Myocardial Demand
1. Elevated heart rate
2. Elevated BP
3. Elevated endogenous catecholamines

• Decreased Myocardial Oxygen delivery

1. Decreased diastolic filling
2. Myocardial vessel occlusion
3. Hypoxia
4. anemia
 Treatment
• ABC
• oxygen
• Position patient comfort
• Vitals
• EMS
• Nitroglycerin : spray or tab .4mg repeat three
times every 5 min ( systolic BP>90 mm Hg )
• Aspirin
 Myocardial infarct

• If chest pain > 20 min consider MI

• Cardiac monitor
• Morphine 2 – 4 mg IV
• EMS transport
Adverse drug reactions with
local anesthetics
Types of local anesthetic reactions

• Local anesthetic toxicity

• Drug interactions
• Vasoconstrictor interactions
• Methemoglobinemia
Dosages
How Anesthetic overdose can
occur?
Clinical Signs
 Treatment

• ABC
• Oxygen
• Vitals
• EMS
• Monitor seizures
• Monitor respiration
• Cardiac monitor
Drug interactions
Vasoconstrictor interactions
 Treatment

• ABC
• Patient comfort
• Vitals
• EMS
• Reassurance reaction will pass
• If BP becomes >170 systolic consider
nitroglycerin
 Methemoglobinemia

• Dose dependent reaction

• Administration of Nitrates, amide
containing drugs ( prilocaine, Benzocaine )
• Pathophysiology : oxidation of the iron
within hemoglobin producing
methemoglobin
 Clinical signs

• Cyanosis at methemoglobin levels of 10%

to 20%
• Dyspnea and tachycardia at metHb level
of 35% to 40%
 Treatment

• ABC
• Oxygen
• EMS
• Monitor patient vitals , Cardiac
• Most healthy adults drugs and metabolites
are eliminated
• Methylene blue 1-2 mg/kg IV
 Airway
Allergy
Obstruction
Asthma
Hyperventilation
Allergy and anaphylaxis
 Drug allergy & Anaphylaxis

• Adverse drug reactions occur in 1% to

15% of drug regimens
• Drug allergy < 2% overall except for some
common agents : penicillin ,
cephalosporin, and trimethoprim-
sulfamethoxazole ( Sulfa )
 Risks Factors
• Multiple intermittent exposures
• Parenteral vs oral
• Children less chance of developing reactions to
meds because of shorter exposure times
• Women higher incidence of cutaneous reactions
secondary to their increased exposure to
cosmetics and latex gloves
• Individuals with multiple illnesses ,
polypharmacy
• Allergies to foods
 Gell & Coombs Classification
• Type 1 ( IgE – Mediated Hypersensitivity)
most life threatening
few minutes
• Type 2 ( Cytotoxic / Cytolytic antibody
mediated) IgM or IgG antibodies mediate
• Type 3 ( Immnune complex mediated )
1- 4 weeks, IgM – IgG soluble metabolite
• Type 4 (delayed Hypersensitivity )
sensitized T cell lymphocytes
Signs & Symptoms of minor allergic
reactions
Signs & Symptoms of Anaphylaxis
 Treatment

• ABC
• Establish reaction type
• Activate EMS
• IV access
Medications for treatment
Minor reactions
Anaphylaxis
Management of allergic scenarios
Medications

• Diphenhydramine 50 mg IM , IV
• Epinephrine: .3ml 1/1000 ( 0.3mg )
• Dexamethasone : 20 mg IM , IV
Obstructed airway
 Etiology

• Foreign body aspiration

• Laryngeal edema
Basics treatment of obstructed
airway
Cricothyrotomy
Asthma
 Types of Asthma

• Extrinsic : allergic asthma, younger

patients , Type 1 hypersensitivity Rx
• Intrinsic : older patients, nonallergic
factors , cold temperatures, exercise,
stress
Asthma medications
What is asthma ?
• Basically it is slow
progressing
Bronchospasm
Treatment

• Terminate therapy
• Position patient
• Administer B agonist spray Albuterol
• Oxygen
• EMS
• Epinephrine SC or IM 0.3ml ( 1/1000
dilution) Epipen
Hyperventilation
• Usually a patient which suffers from:
panic, phobias, psychiatric disorder

• Identify patient early

 Signs and symptoms
• Sighing • Altered consciousness
• Tachypnea • Muscle cramp
• Shortness of breath • Tremor
• Pain on respiration • Myalgia
• Tachycardia
• Nonradiating chest pain
• Lungs clear to
auscultation
• Normal oxygen saturation
• Dizziness
• faintness
 Treatment

• Reassurance
• Slow down breathing
• Comfortable position
• Remove any visual stimuli
• Vitals
• Full rebreathing bag
• Anxiolytic meds , Diazepam ?
 Bibliography

• Handbook of Medical Emergencies in the

Dental Office, Stanley F. Malamed
• Medical Emergencies in Dentistry, Jeffrey
D. Bennett , Morton B. Rosenberg
• ACLS provider manual , American Heart
Association