Mohammad A. Elshall, BDS, MSc, PhD Assist Prof and Consult Oral& Maxillofacial Surgery College of Dentistry King Saud University

Common Emergency Situations are: Fainting (Vasovagal Syncope ) Fainting (Vasovagal Syncope ) Diabetic Coma Diabetic Coma Anaphylactic Shock Anaphylactic Shock Epileptic Seizures Epileptic Seizures Cardiovascular Collapse (CVC) Cardiovascular Collapse (CVC) Thyroid Crises Thyroid Crises Adrenal Crises Adrenal Crises Asthmatic Attack Asthmatic Attack Stroke (Cerebro-vascular Accident, CVA) Stroke (Cerebro-vascular Accident, CVA)

Sudden loss of consciousness Sudden loss of consciousness Chest pain & dyspnea Chest pain & dyspnea Convulsions (fits) Convulsions (fits)

Predisposing factors Signs & symptoms Differential diagnosis (The Main Problem of every Systemic Condition) ManagementReassess (The General Procedures of Maintaining the Pt Life; VS + Specific Management for each Condition)

Vaso-vagal syncope Vaso-vagal syncope Acute Hypoglycaemia Acute Hypoglycaemia Anaphylactic shock Anaphylactic shock Steroid crisis Steroid crisis Myocardial Infarction Myocardial Infarction Cardiac Arrest Cardiac Arrest CVA CVA

Angina Angina Myocardial Infarction Myocardial Infarction Asthma Asthma Anaphylactic Shock Anaphylactic Shock

Epilepsy Epilepsy Any other cause of loss of consciousness including fainting Any other cause of loss of consciousness including fainting

Anxiety Anxiety Pain Pain Injections Injections Fatigue Fatigue Hunger Hunger

Lay flat & lift legs Lay flat & lift legs Loosen tight clothing around neck Loosen tight clothing around neck Give sweetened drink on regaining consciousness Give sweetened drink on regaining consciousness Prolonged faint, Atropine 600 mcg/ml slow IV (1 ml only) Prolonged faint, Atropine 600 mcg/ml slow IV (1 ml only)

Good history Good history Reassurance Reassurance General Anxiety (Stress) Reduction Protocol General Anxiety (Stress) Reduction Protocol Well fed prior to treatment Well fed prior to treatment Glucose drink Glucose drink 10 mg Temazepam nocte (prior to appt) & 1 hour before treatment 10 mg Temazepam nocte (prior to appt) & 1 hour before treatment Delay the procedure Delay the procedure

Drugs e.g. penicillin Drugs e.g. penicillin Insect stings Insect stings Foods, nuts, shellfish, materials Foods, nuts, shellfish, materials Quicker onset the more severe the reaction Quicker onset the more severe the reaction Widespread vasodilatation & increase in capillary permeability, potentially fatal hypotension Widespread vasodilatation & increase in capillary permeability, potentially fatal hypotension

Immediate IgE mediated Anaphylaxis Urticaria Angio-oedema Allergic Asthma Rhinitis

HypersensitivityHypersensitivity

Signs & Symptoms variable Signs & Symptoms variable Rapid weak or impalpable pulse Rapid weak or impalpable pulse Facial flushing, itching, tingling, cold extremities Facial flushing, itching, tingling, cold extremities Bronchospasm (wheezing) Bronchospasm (wheezing) Loss of consciousness Loss of consciousness Pallor going on to cyanosis Pallor going on to cyanosis Cold, clammy skin Cold, clammy skin Facial oedema & sometimes urticaria Facial oedema & sometimes urticaria Deep fall in BP Deep fall in BP

Lay flat with raised legs Lay flat with raised legs Give Adrenaline (1:1000) ml SC or IM Give Adrenaline (1:1000) ml SC or IM Hydrocortisone 200 mg i.v. Hydrocortisone 200 mg i.v. Chlorpheniramine mg slow i.v. Chlorpheniramine mg slow i.v. Give oxygen 6L/min & assisted ventilation Give oxygen 6L/min & assisted ventilation Consider Cricothyrotomy if NO quick improvement Consider Cricothyrotomy if NO quick improvement Call an ambulance Call an ambulance

CAUSES: Overdose of insulin Overdose of insulin Prevented from eating at expected time Prevented from eating at expected time MANAGEMENT: Glucose tablets/powder Glucose tablets/powder If unconscious give 50ml 50% glucose IV If unconscious give 50ml 50% glucose IV SC glucagon 1mg SC glucagon 1mg

Hypoglycaemia Rapid onset Irritability Moist skin Pulse full & rapid More common Less Severe Easy to be managed Hyperglycaemia Slow onset Drowsiness/disorientation Dry skin & mouth Pulse slow & weak Rare More Severe Difficult to be managed

Precipitating Factors: Infection Infection Surgery Surgery Trauma Trauma Pregnancy Pregnancy Other Physiologic or Emotional Stress Other Physiologic or Emotional Stress

Manifestations: Hyperpyrexia (Fever) Hyperpyrexia (Fever) Tachycardia Tachycardia Agitation Agitation Palpitation Palpitation Nausia, Vomiting Nausia, Vomiting Abdominal pain Abdominal pain Loss of Consciousness (Partial or Complete) Loss of Consciousness (Partial or Complete) Management: Terminate all dental ttt Terminate all dental ttt Summon medical assist Summon medical assist Administer O2 Administer O2 Monitor VS Monitor VS Initiate BLS, if necessary Initiate BLS, if necessary Start IV line & Fluids Start IV line & Fluids Transport to ER Care Transport to ER Care

Stress Conditions CAUSES: Stress Conditions GA Surgical/Other trauma Infection Other stress SIGNS & SYMPTOMS Pallor Weakness Nausia Rapid, weak or impalpable pulse Loss of consciousness Rapidly falling BP

Lay flat and raise legs Hydrocortisone 200mg i.v. Give oxygen Monitor VS Start BLS if necessary Consider other possible reasons for loss of consciousness Ambulance & transfer to hospital

Anxiety Infection or exposure to specific allergen Loss or forgetting to bring Salbutamol inhaler

Breathlessness Breathlessness Expiratory wheezing may be disguised as shallow breathing Expiratory wheezing may be disguised as shallow breathing Rapid pulse over 110 Rapid pulse over 110 Accessory muscles of respiration brought into use Accessory muscles of respiration brought into use Cyanosis of mucous membrane & nail beds Cyanosis of mucous membrane & nail beds Mental confusion Mental confusion

Reassure the patient DO NOT lay the patient flat Give the anti asthmatic drug normally used Give oxygen Give Adrenaline Hydrocortisone 200 mg i.v. Monitor VS If no response to Salbutamol 500 mcg i.m/s.c., CALL AN AMBULANCE

Acute chest pain which may radiate to left arm or shoulder Relieved by anti anginal drug e.g. GTN 0.5mg sublingually Aspirin 300mg If symptoms do not resolve rapidly with administration of GTN, consider it likely that the patient has suffered an MI

Severe, crushing retro- sternal pain Feeling of impending death Weak or irregular pulse Pain may radiate to left shoulder, arm or jaw Shock, loss of consciousness Vomiting

Place patient in a comfortable position allowing easy breathing Send for an ambulance Give 50/50 Nitrous Oxide/Oxygen or Oxygen only Aspirin 300mg Good pain control Constant reassurance

Myocardial Infarction Myocardial Infarction Hypoxia Hypoxia Anaesthetic overdose Anaesthetic overdose Anaphylaxis Anaphylaxis Severe hypotension Severe hypotension

Loss of consciousness Absence of arterial pulse “SUMMON HELP” Patient on flat, firm surface CLEAR AIRWAY (keep patent) Start CPR Defibrillation Transfer patient to hospital

Severe Headache Severe Headache Weakness or Paralysis of arms or legs of one side Weakness or Paralysis of arms or legs of one side Unilateral Facial muscle Paralysis Unilateral Facial muscle Paralysis Difficulty or inability to Speak Difficulty or inability to Speak Partial or Total Loss of consciousness Partial or Total Loss of consciousness Patient is very anxious, needs reassurance and transfer to hospital immediately, BLS, Supine Position BUT Head slightly Elevated Patient is very anxious, needs reassurance and transfer to hospital immediately, BLS, Supine Position BUT Head slightly Elevated

Predisposing factors: Anxiety Anxiety Hunger Hunger Menstruation Menstruation Alcohol Alcohol External stimuli, flashing lights etc External stimuli, flashing lights etc Non compliance with medications Non compliance with medications

Warning cry Warning cry Immediate loss of consciousness Immediate loss of consciousness Rigid (tonic phase) Rigid (tonic phase) Widespread jerking (clonic phase) Widespread jerking (clonic phase) Vomiting Vomiting Flaccid after a few minutes Flaccid after a few minutes Consciousness is regained after a variable period Consciousness is regained after a variable period Patient may remain confused Patient may remain confused

Prevent patients from damaging themselves Prevent patients from damaging themselves Place in Supine position Place in Supine position Maintain patent airway Maintain patent airway No medications, await recovery No medications, await recovery Recovery position after fits have ceased Recovery position after fits have ceased Suctioning & Monitor VS Suctioning & Monitor VS Oxygen Oxygen Reassure on recovery Reassure on recovery After fully recovered requires an escort home After fully recovered requires an escort home

Continuous or repeated convulsions for 15 minutes (patient can have severe anoxia) Give 10mg Midazolam IV repeat if no recovery within 10 minutes Maintain airway & give oxygen Call an ambulance, transfer to hospital

The Recovery Position

Telephone Telephone Oxygen cylinder Oxygen cylinder Laerdal pocket mask/Ambubag for hand ventilation Laerdal pocket mask/Ambubag for hand ventilation Disposable airway (Sizes1-4) Guedel Disposable airway (Sizes1-4) Guedel Disposable syringes (2,5,50 ml) Disposable syringes (2,5,50 ml) Disposable needles (23g) Tourniquet Cannulae (20g) Portable suction equipment Sphygnomanometer/Aut omatic BP machine Pulse oximeter

Adrenaline 1:1000, 0.5 ml ampoules Glyceryl trinitrate 500 mcg spray Aspirin 300 mg Hydrocortisone 100mg vials Chlorpheniramine 10 mg Salbutamol 100 mcg (metered inhaler) Morphine sulphate tablets 10 mg Midazolam 10 mg Glucagon 1 mg ampoules Glucose powder or dextrose injection 50%

Adequate training Adequate training Protocols Protocols Medical history Medical history Prevention Prevention Checks& Updating Checks& Updating