Emergency in Dentistry: Part II Hypersensitivity Chest discomfort Chest discomfort Respiratory difficulty Respiratory difficulty Altered consciousness Altered consciousness Metabolic problems 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 ManifestationManagement Delayed onset skin signs: Erythema, urticaria, pruritis, angioedema 1. Stop all drugs that currently use 2. IM or IV Allermin/CTM or Benadryl p.o. 3. Prescribe antihistamine Immediate onset skin signs: Erythema, urticaria, pruritis, angioedema 1. Stop all drugs that currently use 2. SC, IM or IV Epinephrine (1:1000) 0.3ml, q5m if S & S progress 3. IM or IV Allermin/CTM or Benadryl p.o. 4. Monitor vital signs 5. OBS for 1 hr and prescribe antihistamine

ManifestationManagement Respiratory signs (wheezing, mild dyspnea) with or without skin signs 1. Stop all drugs that currently use 2. In sitting position and give O 2 3. Prescribe epinephrine and antihistamine 4. Steam inhalation with bronchodilator (Atroven + Berotec or Ventolin) Stridorous breathing (crowing sound), moderate~severe dyspnea Same as above and prepare to ER Epinephrine Nasal cannula

ManifestationManagement Anaphylaxis Anaphylaxis (with or without skin signs): malaise, wheezing, moderate~severe dyspnea, stridor, cyanosis, total airway obstruction, nausea & vomiting, abdominal cramps, urinary incontinence, tachycardia, hypotension, cardiac dysrhythmia, cardiac arrest 1. Stop all drugs that currently use 2. Put the p’t in supine position on back board and give O 2 3. Administer epinephrine/antihistamine as above 4. Monitor vital signs and prepare for BLS 5. Steam inhalation with bronchodilator (Atroven + Berotec or Ventolin) 6. Consider if cricothyrotomy if laryngospasm cannot relieved

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

Differential Diagnosis of Acute Chest Pain: Uncommon Causes Cardiovascular: Cardiovascular: pericarditis, dissecting aneurysm Respiratory: Respiratory: pulmonary embolism, pleuritis, tracheobronchitis, mediastinitis, pneumothorax Gastrointestinal: Gastrointestinal: esophageal rupture, achalasia Musculoskeletal: Musculoskeletal: chostochondritis Psychologic: Psychologic: psychogenic chest pain

Chest Discomfort: --- AMI or angina pectoris Pain pattern - Characteristics: squeezing, bursting, pressing, burning or choking - Location: substernum - Refer pain: L’t 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 2.Semi-reclined position 3.Sublingual NTG 4.O 2 5.Check vital signs Still discomfort after 3min Discomfort relieved Give 2 nd NTG Give 3 rd NTG 6. Assume angina pectoris was present 7. Slowly taper O 2 over 5min 8. Modify dental treatment Angina pectoris Angina pectoris NTG 0.6mg/tab

10. Assume myocardial infarction in progress 11. On IV line 12. Prepare transport to ER MONA: M orphine, O xygen, N TG, A spirin If highly suspected AMI

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

1.Terminate all procedures 2.Fully sitting position 3.Bronchodilators (Atrovent/Berotec) 4.O 2 5.Check vital signs Signs & symptoms continue S & S relieved 6. Give Epi 0.3ml of 1: 1,000 IM or SQ or SQ 7. Build up IV line 8. Monitor vital signs 9. Prepare to ER 10. Add steroid therapy 6. Monitor of recovery state 7. Consult physician S & S not relieved Asthma Asthma

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

Manifestations of Hyperventilation Syndrome: Cardiac - palpitations - tachycardiaMusculoskeletal - myalgia - muscle spasm - tremor - tetanyPsychologic - extreme anxiety

Management of Hyperventilation Syndrome: Terminate all procedures On fully upright position Verbally calm patient CO 2 -enriched air Breath CO 2 -enriched air Valium 10mg IM or IV; Dormicum 5mg IM or IV 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 Compensatory mechanisms cause increased HR, feeling of warmth, pallor, perspiration, rapid breathing Decompensation occur Reduced cerebral blood flow Lightheadness, syncope Seizure activity Reflex vagally mediated bradycardia, nausea, weakness & hypotension Decreased ABP (if prolong) Vasovagal syncope Vasovagal syncope

Prodrome: Terminate all proceduresTerminate all procedures Supine position with leg elevationSupine position with leg elevation Attempt to calm patientAttempt to calm patient Cool towel to foreheadCool towel to forehead Monitor vital signsMonitor vital signs Syncopal episode: 1.Terminate all procedures 2.Supine position with leg elevation 3.Check breathing If absent: 4. Start BLS 5. Prepare to ER 6. Consider other cause If present: 4. Ammonia under nose 5. Monitor vital signs 6. Plan anxiety control at next visit Vasovagal syncope Vasovagal syncope Atropine 1mg/amp Used in severe bradycardia Not exceed 2mg

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 1.Place on side and suction airway 2.Monitor vital signs 3.Initiate BLS 4.Administer O 2 5.Prepare to ER 1.Diazepam 5mg/min IV 2.Dormicum 3mg/min IV or IM 3.Dialantin 10~15mg/kg IV 1.Suction airway 2.Monitor vital signs 3.Administer O 2 4.OBS for at least 1hr and consult physician Patient unconscious Patient conscious If sustained

MildModerateSevere Hunger Nausea Mood change Weakness Tachycardia Perspiration Pallor Anxiety Behavior change Hypotension Unconsciousness seizures Manifestation of acute hypoglycemia

Terminate all procedures Mild S & S: Administer oral glucose sourceAdminister oral glucose source Monitor vital signsMonitor vital signs Consult physicianConsult physician Intake before next visitIntake before next visit Moderate S & S: 1.Administer oral glucose source 2.Monitor vital signs 3.IV D50, 50ml or glucagon 1mg 4.Consult physician Severe S & S: 1.IV D50, 50ml or glucagon 1mg 2.Prepare to ER 3.Monitor vital signs 4.Give O 2 Hypoglycemia Hypoglycemia

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 O 2 Monitor vital signs Set up IV line Start BLS if indicated Decardron 5mg Hydrocortisone 100mg

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ManifestationsManagement Mild: talkativeness, anxiety, slurred speech, confusion Stop administer L.A. Monitor vital signs OBS in office for 1 hr Moderate: stuttering speech, nystagmus, tremors, headache, dizziness, blurred vision, drowsiness Stop administer L.A. Monitor vital signs Place in supine position Administer O2 OBS in office for 1 hr Severe: seizure, cardiac dysrhythmia or arrest Place in supine position If seizure attack  seizure algorism Institute BLS if necessary Prepare to ER Manifestation and management of local anesthesia toxicity

Suggested maximum dosage of local anesthetics Local anesthetics Maximum No. 2% Lidocaine with Epinephrine 10 Mepivacaine6