Prevention and Management of medical emergencies. By Dr: Waleed A Aabdulaah Bds, Msc, Phd Assistant professor of maxilofacial surgery King Saud University

Preparation for medical emergencies _ Personal continuing education -- auxiliary staff education --- establishment and periodic testing of a system to access medical assistance ----equipping office with supplies necessary for emergency care

Basic life support Abcs: A: air way B: breathing C: circulation

Emergency supplies for the dental office: -Establishing and maintenance of iv access. -- high-volume suction --- drug administration ----Oxygen administration

Hypersensitivity Reactions

Hypersensitivity reactions Skin signs -Delayed onset -stop administration of all drugs -Erythema, urticaria, pruritius -iv or im benadryl 50 mg - refer to physician -Immediate onset -stop administration of all drugs -Erythema, urticaria, -epinephrine 0.3ml of 1:1000 sc,im,or iv pruritius -antihistamine iv, or im -monitor vital signs - consult physician

Respiratory tract signs with or without cardiovascular or skin signs Wheezing, mild dyspnea -stop administration of all drugs -place the patient in sitting position - epinephrine - iv access - consult physician or emergency Stridorous breathing -stop administration of all drugs Moderate to sever dyspnea -sit thee patient upright - epinephrine - oxygen by face mask (6l/m) -- iv access, monitor vital signs - antihistaminic - consult physician

Anaphylaxis ( with or without skin signs) Malaise, wheezing, moderate to -stop administration of all drugs Sever dyspnea, cyanosis, total -position patient supine on - floor air way obstruction, nausea and - epinephrine vomiting, abdominal cramps, - BLS, and monitoring tachycardia, hypotension, - cricothyrotomy Cardiac dysrhythmias, - iv access Cardiac arrest - oxygen 6 l/m - antihistaminic im or iv - prepare for transport

Chest Discomfort

Differential diagnosis of acute onset chest pain: Common causes:- CVS: Angina pectoris, MI. GIT : Gastric ulcers, reflux eosphagitis, dyspepsia. M SK S: Intercostal muscle spasm, rib or muscle contusion. Psychogenic: Hyperventilation.

Uncommon causes:- CVS : Pericarditis. GIT : Esophageal rupture. M SK S: Osteocondritis. RESP S: Pulmonary embolism, pleuritis, mediastinitis, pneumothorax. Psychogenic: imagined chest pain

Clinical characteristics of chest pain caused by myocardial ischemia or infarction: Pain or discomfort described by the patient: 1- Squeezing, pressing, burning, choking, or crushing in character ( not typically sharp or stabbing in quality) 2- Substernally located with variable radiation to : left shoulder, arm, left side, or combination of these areas with neck and mandible.. 3- Frequently associated with: exertion, heavy meal, anxiety, or assuming horizontal position. 4- Relived with vasodilator (nitroglycrin), or rest (as in angina). 5- accompanied by dyspnea, nausea, weakness,, palpitations

Management of patient with chest pain:- 1- terminate all procedures 2- position patient in semi-reclined position 3- give nitroglycrin (TNG) 0.4 mg tab or spray 4- oxygen 5- check pulse and blood pressure Discomfort relived 6- assume angina p. present 7- slowly taper oxygen. 8- modify dental treatment Discomfort continues after 3 m of TNG 6- Give 2ed TNG dose. 7- monitor vital signs Discomfort continues after 3 m of TNG 8- Give 3ed TNG dose. 9- monitor vital signs

Discomfort relived 10- refer patient to medical evaluation before further dental care Discomfort continues after 3 minutes of 3ed TNG 10- Assume MI in progress. 11- start IV line 12- to relive the discomfort; morphine sulfate 2mg subcutaneously or intravenously every 3 minutes until pain relived. 13- prepare for transport to emergency care.

Respiratory Difficulty

Respiratory Difficulty: -Asthma -Hyperventilation -Foreign-body aspiration

Manifestations of acute asthmatic episode Mild to moderate: -Wheezing Dyspnea Tachycardia Coughing Anxiety Asthma

Sever: -Intense dyspnea ( with flaring of the nostrils, and use of accessory muscles of respiration. -Cyanosis -Minimal breath sound. -flushing of the face -Mental confusion - prespiration.

Management: 1- terminate the procedures 2- patient in fully sitting position. 3-bronchodilator (isoproterenol). 4- oxygen. 5- monitor vital signs Relived: 6- STILL monitoring 7- DC IV lines. 8-no dental ttt until consultation. Not relived: 6- Epinephrine 0.3ml of 1/1000 IM or Sc 7-IV line with crystalloid solution 30ml/h 8-monitor vital signs Not relived: 9- Theophylline 250 mg IV, and cortisone 100mg IV 10- Prepare for transport to emergency care

Hyperventilation syndrome

Manifestations of hyperventilation syndrome: Neurologic; Dizziness Numbness of fingers, toes, lips syncope Respiratory; Increase rate and depth of breath Feeling of shortness of breath Chest pain xerostomia Cardiac; Palpitations, tachycardia Musculoskeletal; Myalgia, muscle spasm, tremor, tetany Psychologic; anxiety

Management: 1- terminate all procedures’ 2-Patient in almost fully upright position. 3-verbally calm the patient 4- patient breath Co2 enriched air, such as in a small bag. Symptoms persist ; 5-diazebam 10mg IM or slowly IV until anxiety relived. 6- monitor vital sings 7- perform all further dental procedures using anxiety reducing measures

Foreign- body aspiration

Manifestations Large foreign body -coughing -choking sensation -stridorous breathing -dyspnea -Feeling something caught in throat -Inability to breath -Cyanosis -Loss of consciousness Gastric content -coughing -stridorous breathing -wheezing -tachycardia -hypotension -dyspnea -cyanosis

Management 1- terminate all procedures 2-pt in sitting position 3-ask the pt. To cough the object out Unconscious pt. 4-medical assistance 5-supine position 6-begin abdominal thrusts followed by turning pt. on side and use the finger to sweep the oral cavity for foreign body 7-ventillate Conscious pt.

Able to ventilate 8-BLS 9-O2 10- Transport Unable to ventilate 8-repeat steps 6,7 twice then 9-laryngoscope 10-cricothyrotomy

Conscious pt. Symptoms persist 4-heimlich maneuvers Symptoms stopped, or ceased, you unsure where is the foreign body 4-O2 5-Monitor vital signs 6-transport, radiograph, and bronchoscope 5- O2 6-medical assistance 7-monitor vital signs 8-transport

Altered Consciousness

Altered consciousness: Vasovagal syncope. -Orthostatic hypotension. -Seizure -Local anesthetic toxicity -Diabetes mellitus. -Thyroid dysfunction -Adrenal insufficiency - Cerebrovascular compromise

Vasovagal syncope

Pathophysiology of vasovagal attack anxiety Catecholamine release peripheral vascular resistance Pooling of blood in periphery arterial blood pressure heart rate, warmth, perspiration, reapid breathing decompensation Reflex vagally mediated bradycardia, nausea, hypotension Reduced cerebral blood flow syncope seizure

Management: Prodrome; 1- terminate all procedures. 2-supine position, legs elevated 3-calm the patient 4-place cool towel on patient forehead 5-monitor vital sings.

Syncope: 1- terminate all procedures 2-supine position and legs elevated. 3-check for breathing If absent; 4-start basic life support 5- search medical assistance 6-consider other causes of syncope If present; 4- ammonia under nose 5- O2 6- monitor vital signs 7- anxiety control measures during future dental ttt.

Orthostatic hypotension

Management: 1- Terminate all procedures 2- patient in supine position with legs elevated 3-monitor vital ssigns 4-once blood pressure improves, slowly return patient to sitting position. 5-discharge to home once vital sings are normal 6- medical consultation before any future dental treatment.

Seizure

Seizures Manifestations (I) Isolated, brief seizure Tonic-clonic movements of trunk and extremities, loss of consciousness, vomiting, air way obstruction, loss of anal and urinary sphincter control Acute management 1- terminate all dental procedures 2-place in supine possition 3-protect from nearby objects

After seizure Unconscious pt. 4- medical assistance 5-pt. on side and suction air way 6-monitor vital signs 7-basic life support 8-O2 9-transport to emergency care Conscious pt. 4-Suction air way 5-monitor vital signs 6-O2 7-consult physician

(II) Repeated or sustained seizures ( status epilepticus) Acute management; 1- diazepan 5mg/min IV up to 10 mg or midazolam 3mg/min up to 6 mg. 2-medical assistance 3-protect patient from nearby objects Once seizures ceases; 4- pt. on side, and suction air way. 5-monitor vital signs. 6-Basic life support. 7-O2 8-transport to emergency care.

Local anesthetic toxicity

Manifestations; Mild toxicity: talkativeness, anxiety, slurred speech, confusion Management; -Stop administration of local anesthesia -Monitor all vital signs -Observe for 1 h

Moderate toxicity; Stuttering speech, headache,dizziness, blurred vision, drowsiness Management; -Stop administration of local anesthesia - Supine position -Monitor all vital signs - O2 -Observe for 1 h

Sever toxicity; Seizure, cardiac dysrhythmia or arrest Management; -supine position -protect from nearby objects -Suction oral cavity if vomiting occur -Medical assistance -Monitor all vital signs -O2 - Start IV -DIAZEPAM 5-10 mg slowly or midazolam 2-6 mg -Basic life support -Transport to emergency care

Diabetes Mellitus

Manifestations off acute hypoglycemia Mild Hunger Nausea Mood change weakness Moderate Tachycardia Prespiration Pallor Anxiety Behavior change; Confusion uncooperativness Sever Hypotension Unconsciousness seizures

Mangement; Mild hypoglycemia; -glucose source like sugar or fruit by mouth -monitor vital signs -consultation before future dental treatment

MODERATE HYPOGLYCEMIA -glucose source like sugar or fruit by mouth -monitor vital signs -If symptoms do not improve, administer 50 ml 50% glucose or 1 mg glucagon IV or IM - Consultation

Sever hypoglycemia -50 ml of 50% glucose IV, or IM, or 1mg glucagon -Medical assistance -Monitor vital signs -O2 -Transport to emergency care

Thyroid dysfunction

Manifestations -hyperpyrexia -tachycardia -nervousness -tremor -weakness -palpitations -cardiac dysrhythmias -nausea and vomiting -abdominal pains -Partial or complete loss of conciousness

Management -Terminate all procedures -Medical assistance -O2 -Monitor vital signs -BLS -IV line with crystalloid solution -Transport to medical emergency care

Adrenal insufficiency

Manifestations -weakness -feeling of extreme fatigue -confusion -hypotension -nausea -abdominal pain -myalgias -partial or total loss of consciousness

Management; -terminate all procedures -supine position with legs elevated -medical assistance -corticosteroids (100mg of hydrocortisone IM or IV -O2 -monitor vital signs -IV line -BLS --transport to emergency care

Cerebrovascular compromise

Manifestations; -headache -unilateral weakness or paralysis of extremities or facial muscles or both. -slurring of speech or inability to speak -difficulty of breathing or swallowing or both -loss of bladder control -seizures -visual disturbance -dizziness -partial or total loss of consciousness

Management; -terminate all procedures -medical assistance -supine position with head slightly raised -monitor all vital signs -If loss of consciousness; O2, BLS. -Transport to emergency care

Thank You