Overall Classification: UNCLASSIFIED//REL TO NATO/ISAF

Definition:  A serious unpredictable, unexpected potentially dangerous situation that require immediate action.  It can progress to mortality or neurological deficit in a short space of time if not properly managed

 Prevention is accomplished by conducting a thorough medical history with appropriate alterations to dental treatment as required.

 Practice, Practice, Practice  Check Emergency Drugs and Oxygen At Least Monthly  Know Who to Call in Case of Emergency  Arrange for Assistance in Advance with Nearby Medical Personnel

 Review Medical History at EACH Appointment  Determine Medication Compliance ◦ Did the Patient Take Their Medication Today??

 Take Vital Signs, Particularly Older Patients  Determine Apprehension Level  How Are You Feeling Today??

 Blood Pressure  Heart Rate  Respiratory Rate  Temperature

Stress  Is the major cause of medical emergencies in the dental office

 Good Patient Relations  Morning Appointment  Most emergencies occur during or immediately after the admistration of local anesthesia or at the beginning or a procedure.

The types of procedures during medical emergencies most frequently arise: Tooth Extractions  Endodontic treatment

Oxygen:  The most frequently used “drug” in medical emergency

Epinephrine 1:1000  Allergic reaction

Diphenhydramine (Benadryl)  Allergic reaction

Nitroglycerin  Angina

Glucose  Hypoglycemia

 Syncope  Hyperventilation  Foreign Body Aspiration  Allergy & Anaphylaxis  Acute Asthmatic Episode  Hypoglycemic Shock  Chest Pain  Seizure  Stroke

 Basic Life Support (BLS-C)  Emergency Management Protocol and Plan  Recording of Vital Signs

 Vasovagal Syndrome  Most Common Emergency in Office  Men > Woman  Younger Ages   Frequently During LA Injection

Symptoms:  Feeling of warmth  Nausea  Perspiration  Pale skin color  Lower blood pressure

Response Steps:  Place the patient in supine position (with the head lower than the feet)  Loosen any binding clothes  Have oxygen ready to administer  Monitor and record vital signs  If unresponsive, call for emergency assistance

 Occur when the patient assumes an upright position too quickly  Symptoms: ◦ Low blood pressure ◦ Altered state of consciousness

Response steps:  Place the patient in supine position (with the head lower than the feet)  Slowly move the patient into an upright position  Monitor and record vital signs  If unresponsive, call for emergency assistance

If postural hypotension:  Turn onto her left side

 A cerebrovascular accident (CVA), commonly referred to as a stroke  Is a interruption of blood flow to the brain

 If blood flow is interrupted for a sufficient duration, damage to the brain may occur, resulting in loss of brain function.

 Most CVAs occur in older individual who have other predisposing diseases, such as arteriosclerosis, heart disease, or uncontrolled high blood pressure.

Signs and Symptoms:  Paralysis  Speech problems  Vision problems  Possible seizure  Difficulty swallowing  Headache  Unconsciousness

Response Steps:  Call for emergency assistance  Initiate basic life support (CPR) if the patient becomes unconscious  Monitor and record vital signs

Is It Angina Pectoris, Myocardial Infarction Or Something Else???

 Pain from angina usually last 3 to 8 minutes  Angina pain is relieve or eased promptly by the administration of sublingual nitroglycerin (spray or tablet)

 A patient with history of angina usually carries some form of nitroglycerine to relieve the symptoms of an attack  Even if a patient has a history of angina, when an attack strikes, it is important to remember that the patient could be having a heart attack

Symptoms:  Tightness or squeezing sensation in the chest  Pain radiating to the left shoulder  Pain radiating to the left side of the face, the jaws and the teeth

Response steps:  Call for emergency assistance  Position the patient upright  Help the patient to medicate himself with nitroglycerin  Administer oxygen  Monitor and record vital signs

 During a heart attack, the muscle of the heart are damaged because of an insufficient oxygen supply

 Any unexplained chest pain should be treated as a potential heart attack

Symptoms:  Chest pain ranging from mild to severe  Pain in the left arm, the jaws and the teeth  Shortness of breath and sweating

Symptoms:  Nausea and vomiting  Pressure, aching or burning feeling of indigestion  Generalized feeling of weakness

Response steps:  Call for emergency assistance  Initiate basic life support (CPR) if the patient becomes unconscious

Response steps:  Medicate with nitroglycerin and an aspirin tablet from the office’s emergency kit  Administer oxygen  Monitor and record vital signs.

 Is precipated (initated) by stress and anxiety  Is an increase in the frequency or depth of respiration  Patient usually remains conscious

Signs and Symptoms:  Rapid, shallow breathing  Panic-stricken appearance  Lump in the throat

Response Steps:  Place the patient in a comfortable position  Use quiet tone of voice to calm and reassure the patient

Response Steps:  Have the patient breathe into cupped hands

 Airway narrows, causing difficulty in breathing, coughing and a wheezing sound  An allergic reaction, severe emotional stress or respiratory infection may cause an asthma attack

Signs and Symptoms:  Coughing  Wheezing  Pallor  Cyanosis (bluish skin)

Response Steps:  Call for assistance  Position the patient upright  Help the patient self- medicate with an inhaler  Administer oxygen as needed  Assess and record vital signs

 Altered state of reactivity  Every drug or dental material introduced to a patient can produced a reaction

Two factors to consider when managing an allergic reaction:  The speed which symptoms appear  The severity of the reaction The symptoms of anaphylaxis can be life threatening and may develop very quickly. Without appropriate care the patient could die within a few minutes.

Localized Rash: Signs and Symptoms:  Itching  Skin redness  Hives

Localized Rash: Response Steps:  Identify area of rash  Monitor vital signs  Prepare an antihistamine for administration or we can give Benadryl to the patient  Be ready for Basic life support  Refer for medical consultation

Anaphylaxis: Signs and Symptoms:  Feeling physically ill  A feeling of warmth  Nausea and vomiting  The sensation of a lump in your throat

Anaphylaxis: Signs and Symptoms:  Constriction of the airways and a swollen tongue or throat, which can cause wheezing and trouble breathing  Irregular heartbeats  Sudden drop in blood pressure  Loss of consciousness

Anaphylaxis Response Steps:  Call for emergency assistance  Place the patient in a supine position  Start Basic life support (CPR) if the patient becomes unconscious

Anaphylaxis Response Steps:  Prepare to administer epinephrine (epipen)

Anaphylaxis Response Steps:  Administer oxygen  Monitor and record vital signs

 Is a neurologic disorder that is characterized by recurrent episodes of seizures  Types: ◦ Grand mal seizure ◦ Petit mal seizure

Grand mal seizure:  Is characterized by a temporary loss of consciousness accompanied by uncontrollable muscular contractions and relaxation

Petit mal seizure:  Is a brief lapse of consciousness that may last only a few second  A patient may just stare or may no movement during the period  The patient usually does not collapse

Grand mal seizure:  Aura. feeling a sense of unexplained dread, a strange smell or a feeling of numbness.  A scream. Some people may cry out at the beginning of a seizure  Loss of bowel and bladder control. This may happen during or following a seizure.  Unconsciousness

Grand mal seizure:  Unresponsiveness after convulsions. Unconsciousness may persist for several minutes after the convulsion has ended.  Confusion. A period of disorientation often follows a grand mal seizure.  Fatigue. Sleepiness is common after a grand mal seizure.

Grand mal seizure: Response steps:  Call for emergency assistance  Quickly remove all material from the mouth and place the patient in a supine position  Do not place nothing in the patient’s mouth

Grand mal seizure: Response steps:  Protect the patient from self-injury during movements  Initiate Basic life support if necessary  Monitor and record vital signs  Note how long the seizure lasts.

Petit mal seizure: Signs and Symptoms:  Intermittent blinking  Mouth movements  Blank stare  Seems to be in his or her “own world”

Petit mal seizure: Response Steps:  Protect patient from self-injury  Monitor and record vital signs  Refer patient for medical consultation

 Is a metabolic disorder that results from disturbances in the body’s normal insulin mechanism.

 When the balance shifts, with too much or too little food ingested, insulin levels can change, resulting in hyperglycemia (too much blood sugar) or hypoglycemia (too little blood sugar).

 Abnormal increase in the glucose (sugar) level in the blood.  If untreated, may progress to a life- threatening diabetic coma

Signs and Symptoms:  Excessive urination  Excessive thirst, dry mouth and dry skin  Acetone breath (fruity smell)  Blurred vision and headache  Rapid pulse  Lower blood pressure  Loss of consciousness

 If the patient is conscious ask he or she last ate, whether the patient had taken insulin and whether he or she brought insulin along to the dental appointment.  If the patient has already eaten but has not taken insulin, he or she needs insulin immediately.

 Retrieve the patient’s insulin if is available. If Able, the patient should self-administer the insulin  Call for emergency assistance if necessary

 Provide Basic life support (CPR) if the patient becomes unconscious  Monitor and record vital signs

 Hypoglycemia results from an abnormal decrease in the glucose level in the blood.  The most common causes of hypoglycemia consist of skipping a meal, taking too much insulin without adequate food intake and exercising excessively without appropriate adjustment of insulin and food intake.

Signs and Symptoms:  Mood changes  Hunger  Perspiration  Increase anxiety  Possible unconsciousness

Response Steps:  If the patient is conscious ask he or she last ate, whether the patient has taken insulin and whether he or she brought insulin along to the dental appointment.

Response Steps:  Give a concentrated form of carbohydrate, such as a sugar packet, cake icing or concentrated orange juice. These substances will be absorbed rapidly into the bloodstream.

Response Steps:  Call for emergency assistance if necessary  Provide Basic life support (CPR) if the patient becomes unconscious  Monitor and record vital signs

 When a medical emergency arises in the dental clinic, full documentation of the details is essential.

 Anticipate Problems  Always Review Patient’s Medical History  Obtain Pre-op Vital Signs  Patient Supine for Injections

 Have an Emergency Plan  Have Regular Office Emergency Drills  Have Appropriate Emergency Drugs and Know How to Use Them  Keep Current in BLS

Overall Classification: UNCLASSIFIED//REL TO NATO/ISAF