Medical Emergencies In Dentistry - II

By
CYRIAC JOHN
FINAL YR, PART I
 CLASSIFICATON
• Unconsciousness
- Vasodepressor syncope
- Postural Hypertension
- Acute adrenal insufficiency
• Respiratory Distress
- Foreign body airway obstruction
- Hyperventilation
- Asthma
- Heart failure and acute pulmonary edema
• Altered Consciousness
1. Diabetes Mellitus
- Hyperglycemia
- Hypoglycemia
2. Thyroid gland dysfunction
3. Cerebrovascular accident
• Seizure
• Drug related emergencies
- Drug overdose reactions
- Allergy
• Chest pain
- Angina Pectoris
- Acute Myocardial Infarction
 Sudden cardiac arrest
HYPERTENSION

DEFINITION
“ABNORMALLY HIGH BLOOD PRESSURE CREATING SIGNS AND SYMPTOMS
TO THE PATIENT”

RISK FACTORS
• ATHEROSCLEROTIC VASCULAR DISEASE

• HISTORY OF HYPERTENSION
PRECIPITATING FACTORS
• STRESS
• FAILURE TO TAKE MEDICATION

DIAGNOSIS
• HEADACHE
• DIZZINESS
• TACHYCHARDIA
• PALPITATION
• CONFUSION
• NUMBNESS
• LOSS OF LIMB FUNCTION
TREATMENT
• SIT UPRIGHT

• 100 % OXYGEN

• CALL EMERGENCY SERVICES

• ANTIHYPERTENSIVE DRUGS

PREVENTION
• CHECK BLOOD PRESSURE BEFORE PROCEDURE

• ASSURE MEDICATIONS

• STRESS REDUCTION PROTOCOLS

• MONITOR EPINEPHRINE DOSES

ANGINA PECTORIS
DEFINITION

“A CHARACTERISTIC THORACIC PAIN,USUALLY SUBSTERNAL PERCIPITATED CHEIFLY

BY EXERCISE AND MOTION OR A HEAVY MEAL;RELIEVED BY VASODILATOR DRUGS

AND A FEW MINUTES REST;AND A RESULT OF A MODERATE INADEQUACY OF THE

CORONAL CIRCULATION”
PREVENTION

• PROPER MEDICAL HISTORY

• THE PAST MEDICAL HISTORY IN DETAIL

DENTAL THERAPY CONSIDERATION

• AVOID OVER STRESSING THE PT

• SUPPLEMENTAL OXYGEN BY A NASAL CANNULA – 3 – 5 L/MIN

• PAIN CONTROL DURING THERAPY, APPROPRIATE USE OF LA, SMALLER DOSE WITH

MAX. EFFECT – SLOW ADMINISTRATION

• VASODEPRESSOR ADMINISTRATION SHOULD BE MINIMISED IN INCREASED
RISK PT
• MONITORING VITAL SIGNS
• NITROGLYCERINE PREMEDICATION 5MINS BEFORE TREATMENT

CLINICAL MANIFESTATIONS
• PAIN- SUDDEN ONSET OF CHEST PAIN
• DULL ACHING HEAVY PAIN LOCATED SUBSTERNALLY
• RADIATION OF PAIN – MOST COMMONLY TO THE LEFT SHOULDR AND ARM,
LESS FREQUENTLY TO RIGHT SHOULDER ARM, LEFT JAW, NECK AND
EPIGASTRIUM
• PAIN- SUDDEN ONSET OF CHEST PAIN
• DULL ACHING HEAVY PAIN LOCATED SUBSTERNALLY
• RADIATION OF PAIN – MOST COMMONLY TO THE LEFT SHOULDR AND
ARM, LESS FREQUENTLY TO RIGHT SHOULDER ARM, LEFT JAW, NECK
AND EPIGASTRIUM
 ACUTE MYOCARDIAL INFARCTION

• IT IS A CLINICAL SYNDROME CAUSED BY A DEFFICIENT CORONARY

ARTERY BLOOD SUPPLY TO A REGION OF MYOCARDIUM THAT RESULTS
IN CELLULAR DEATH AND NECROSIS.
 PREDISPOSING FACTORS

• ATHEROSCLEROSIS AND CORONARY ARTERY DISEASE.

• CORONARY THROMBOSIS, OCCLUSION AND SPASM

CLINICAL FEATURES
• MALES
• 5TH AND 6TH DECADE OF LIFE
• UNDUE STRESS
 SYMPTOMS

• PAIN- CRUSHING, CHOCKING, PROLONGED , UPTO 30 MINS

• RADIATES TO LEFT ARM, HAND, SHOLDER, EPIGASTRIUM , NECK AND
JAW
• NAUSEA AND VOMITING, DIZZINESS, PALPITATION
• COLD PERSPIRATION
• FEAR OF IMPENDING DOOM
 SIGNS
• RESTLESSNESS
• ACUTE DISTRESS
• SKIN – COOL, PALE AND MOIST
• HEART RATE – BRADYCARDIA TO TACHYCARDIA
 DENTAL THERAPY CONSIDERATIONS

• AVOID OVER STRESSING THE PT

• SUPPLEMENTAL OXYGEN BY A NASAL CANNULA – 3 – 5 L/MIN

• PAIN CONTROL DURING THERAPY, APPROPRIATE USE OF LA, SMALLER

DOSE WITH MAX. EFFECT – SLOW ADMINISTRATION

• VASODEPRESSOR ADMINISTRATION IS A RELATIVE CONTRAINDICATION.

• PSYCHOSEDATION – NITROUS OXIDE AND OXYGEN IS
PREFERRED
• IT IS STRONGLY RECOMMENDED THAT ELECTIVE DENTAL
CARE IS AVOIDED UNTIL ATLEAST 6 MONTHS AFTER MI
• MEDICAL CONSULTATION AND ANTICOAGULATION AND
ANTIPLATELET THERAPY NEED NOT BE ALTERED
• INFERIOR ALVEOLAR NERVE BLOCK AND PSA NERVE BLOCK –
RISK OF HEMORRHAGE – SHOULD BE AVOIDED
 PREVENTION

• PROPER MEDICAL HISTORY

• THE PAST MEDICAL HISTORY IN DETAIL
• VITAL SIGNS SHOULD BE RECORDED BEFORE AND IMMEDIATELY
AFTER DENTAL APPOINMENTS
• VISUAL EXAMINATION – PERIPHERAL CYANOSIS, COOLNESS OF
EXTREMITIES, PERIPHERAL EDEMA, POSSIBLE ORTHOPNEA
POSTURAL HYPOTENSION

“DECREASED BLOOD PRESSURE ASSOCIATED WITH AN ABRUPT

CHANGE IN PT POSITION”
• ORTHOSTATIC HYPOTENSION
PRECIPITATING FACTORS

• RAPID VERTICAL CHANGE IN BODY POSITION IN PERSONS AT RISK

• DEHYDRATION
• BLOOD LOSS
• ALLERGIC REACTION
• MI
CLINICAL FEATURES/DIAGNOSIS

• PT FEELS LIGHT HEADED UPON RAPID STANDING

• LOSS OF CONSCIOUSNESS
• VITAL SIGNS SHOWBLOOD PRESSURE LOW
PULSE NORMAL OR
TREATMENT AND MANAGEMENT

• STOP DENTAL TREATMENT

• REMOVE OBJECTS IN MOUTH
• RAISE FEET
• LOOSEN THE CLOTHING
• SUPPLEMNTAL OXYGEN
• COOL TOWEL TO FOREHEAD
• MONITOR VITAL SIGNS
PREVENTION
• DO NOT ALLOW THE PTs AT RISK TO RAPIDLY STAND FROM THE DENTAL
CHAIR
• ELEVATE THE PATIENTS SLOWLY AND IN STAGES
• BE PREPARED TO PHYSICALLY SUPPORT THE PATIENT IF THEY PASS OUT
BACTERIAL ENDOCARDITIS

DEFINITION
“Infective endocarditis is defined as microbial infection of the endothelial
surfaces of the heart or iatrogenic foreign bodies like prosthetic valves
other intracardiac devices.”
PREDISPOSING FACTORS

• Numbers of bacteria entering the blood

• Ability of bacteria to adhere to endocardium
• Congenital
• Rheumatic and other acquired valvular disease
• Prosthetic heart disease
MANAGEMENT

• A CONSENT LETTER FROM THE DR OVERLOOKING THE PT-STATING PATIENT IS

IS FIT FOR DENTAL PROCEDURES
• Early treatment needed to minimize the cardiac damage. The usual
treatment is intravenous penicillin plus gentamycin for 2 weeks or more
viridians streptococci is the causative orgm
 DENTAL TREATMENT UNDER - LA
Clinical Situation Drug Regimen

Patients not allergic Amoxillin ADULTS

to pencillin Oral amox 3g 1hr. Before
procedure
CHILD
<5yrs : oral amox-250mg 1 hr.
B.Pr
5-10yrs : oral amox-500mg 1 hr.
B.Pr
>10yrs : use adult dose
Patient allergic to Clindamycin ADULTS
pencillin Oral clindamycin
600mg 1 hr before pr.

CHILD
<5 yrs- Oral
Clindamycin 150 mg
1hr. Before pr.
5-10 yrs- oral
clindamycin 300mg 1
hr. bef pr.
<10 yrs – Use adult
dose
 UNDER GA
CLINICAL DRUG REGIMEN
SITUATION

Patient not Amoxicillin ADULTS

allergic to i.v. amox 2g administered upon
penicillin attainment of GA and immediately bef pr.
CHILD
<5yrs-i.v. amox 250mg administered upon
attainment of GA
5-10yrs-oral amox 500mg administered 1
hr. bef pro.
>10yrs- Use adult dose 2g administered
before procedure
Treatment needing Antimicrobial prophylaxis in pts
at risk of IE
• Extractions
• Sub gingival procedures – Probing/card placement.
• Oral/Periodontal implant surgery & flap surgery.
• Endodontics beyond the root apex.
• Sialography
• Intraligamental LA
• Rubber dam matrix/Wedge placement
Procedure in which antimicrobial prophylaxis NOT reqd in persons at
risk of Infective Endocarditis

• Dental Radiography
• Endodontics beyond apex.
• Exfoliation of primary teeth.
• Impression taking.
• Non surgical procedures that not have bleeding.
• Abscess incision and drainage.
• Suture removal, orthodontic band removal
 MEDICAL EMERGENCIES DUE TO
FUNCTIONAL CAUSES

IATROGENIC CAUSES ARE MAINLY

• NEEDLE BREAKAGE
• SWALLOWING OF DENTAL & SURGICAL MATERIALS
• INJURY TO SOFT TISSUE
• INFECTION
NEEDLE BREAKAGE
MAIN CAUSE OF NEEDLE BREAKAGE IS DUE TO
• USING INAPROPRIATE NEEDLE SIZE FOR PROCEDURES
• INJECTING WITHOUT STABILIZING THE SYRINGE BY HOLDING THE
THE HUB OF THE NEEDLE
TREATMENT AND MANAGEMENT
• INFORM AND ENSURE THE PATIENT ABOUT THE INCIDENT
• WITH PROPER CARE AND ASSISTANCE,SURGICALLY REMOVE THE
THE BROKEN SEGMENT
• PROVIDE POST SURGICAL INSTRUCTIONS AND MEDS
SWALLOWING OF DENTAL AND SURGICAL MATERIALS

TREATMENT AND MANAGEMENT

• INFORM AND ENSURE THE PT
• INDUCE VOMITING
• GASTRIC LAVAGE
• MILK THERAPY
INJURY TO SOFT TISSUES
Causes
Accidental slipping of instruments
Inappropriate surgical practices
Treatment and management
Inform and ensure the patient
Control the bleeding if present
Give appropriate medications and instruction
• Infection
Causes
• Unsterile instruments
• Unhygienic practices
• Unsterile environment(clinical surrounding)
• Using one instrument for multiple procedures in diff pts without disinfection
and sterilization
Management
• Sterilize every instrument before starting treatment on a new patient
• Keep the clinical environment clean and sterile
DRUG OVERDOSE REACTIONS
OVERDOSE IS A CONDITION THAT RESULTS FROM EXPOSURE TO TOXIC
AMOUNTS OF A SUBSTANCE THAT DOES NOT CAUSE ADVERSE EFFECTS
WHEN ADMINISTERED IN SMALLER AMOUNTS.

DRUGS AND ADVERSE REACTIONS

• LOCAL ANAESTHETIC
• ANTIBIOTICS
• ANALGESICS
• SEDATIVE HYPNOTICS
• LOCAL ANAESTHETICS
ESTERS
ALLERGY – common, especially with topical anesthetics, manifested as

localized erythema and edema.

Overdose – unlikely with esters, unless genetic deficiency present

Side effects – rare sedation or drowsiness

Management – antidote to la overdose is phentolamine mesylate

• AMIDES
ALLERGY - MOST CLINICAL REPORTS PROVED ALLERGY TO BE
PSYCHOGENIC RXN, OVERDOSE OR ALLERY TO OTHER COMPONENT OF
SOLUTION

OVERDOSE – CNS DEPRESSION MANIFESTED AS DROWSINESS, TREMOR,

TONIC CLONIC SEIZURES

SIDE EFFECTS – RARE, SEDATION MOST COMMON

• ANTIBIOTICS
ALLERGY – HIGH ALLERGIC POTENTIAL TO MANY ANTIBIOTICS
MANIFESTED CLINICALLY OVER ENTIRE SPECTRUM OF ALLERGIC
PHENOMENA.

OVERDOSE – VIRUALLY NON EXISTENT WITH PENICILLIN

SIDE EFFECTS – RARE GI UPSET – MOST COMMON

• ANALGESICS
NON OPIOID
ALLERGY – HIGH ALLERGY POTENTIAL (ASPIRIN)
OVERDOSE – COMMON SALICYLISM

OPIOIDS
ALLERGY – UNCOMMON
OVERDOSE - COMMON, MANIFESTED AS CNS DEPRESSION AND
RESPIRATORY DEPRESSION
SIDE EFFECTS – MOST COMMON ADR, MANIFESTED CLINICALLY AS
NAUSEA, VOMITING, ORTHOSTATIC HYPOTENSION
• SEDATIVE HYPNOTICS
BENZODIAZEPINES
OVERDOSE – CNS DEPRESSION MANIFESTED AS OVER SEDATION
SIDE EFFECTS- PROLONGED DROWSINESS

INHALATION SEDATION (N20-02)

OVERDOSE – COMMON, MANIFESTED AS OVER SEDATION
SIDE EFFECTS – MOST COMMON AREA MANIFESTED AS NAUSEA,
VOMITING
• MANAGEMENT
MANAGEMENT OF OVER SEDATION FOCUSES ON DEREASE IN
PERCENTAGE OF N2O THROUGH AN INCREASE IN THE VOLUME OF FLOW
OF O2 COUPLED WITH THE STEPS OF BLS. P-A-B-C UNTIL THE PT
REGAINS CONSCIOUSNESS.
 Conclusion
• Prompt recognition and efficient management of medical
emergencies by a well prepared dental team can increase the
likelihood of satisfactory outcome.
• The basic aim for managing medical emergency is to ensure that
the pts brain receives constant supply of blood containing oxygen.
 References
• Medical emergencies in dental office: Stanley F Malamed
• Mark greenwood dental emergencies