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UNIT 13: Medical

emergencies in the
dental office II
5. Specific Medical Emergencies
Loss of
consciousness
Syncope
Postural
Hypotension
Hypoglucemia
Respiratory
distress
Hyperventilation
Syndrome
Asthmatic attack/
Bronchospasm
Airway obstruction
Chest pain
Angina pectoris
Acute Myocardial
Infarction (AMI)/
Heart attack
Allergic/ Drug
reactions
Urticaria/ Pruritus
Anaphylatic Shock
Epinephrine
reaction
Drug overdoses
Altered sensation/
Changes in affect
Stroke/
Cerebrovascular
Accident
Seizure Disorders
Panic Attacks
Loss of consciousness
Syncope
Postural Hypotension
Hypoglucemia
CAUSE:
Decreased circulation of blood to the brain.
Factors: pain, anxiety, and heat. It may also result from cardiac or vascular
problems or other causes
SIGNS AND SYPTOMS:
Commonly in young adults
Appearance of pallor at the onset, diaphoresis (profuse perspiration), and
syncope of short duration.
Patient feels distressed, weak and dizzy, and may be nauseated and have moist,
cold extremities.
Diaphoresis and pallor indicate the underlaying bradicardia, hipotension and
vasodilation.
Occasionally, a convulsion may occur.
Loss of consciousness
Syncope
Basic Life Support (BSL):
EMERGENCY STEPS
The basic emergency procedures include 5 fundamental steps to be taken
immediately in every emergency:
Step1
Discontinue
treatment and
assess
consciousness
Step 2
Unobstructe
d airway
Step 3
Check
pulse rate
and its
character
Step 4
Check
blood
pressure
Step 5
Monitor rate
and
character of
respiration
If patient becomes
unconscious
Cardiopulmonary
Resuscitation (CPR)
steps 6a-h
Syncope
EMERGENCY TREATMENT
Steps 1, 2, 3, 4, 5; if the patient loses consciousness, implement Step 6
Step 7 Stimulation of cutaneous reflexes, with a cold towel placed on the
forehead or reflex stimulation with inhalation of aromatic spirits of
ammonia
Step 8 Check the patients blood pressure. If it remains low and pulse
remains slow, administer atropine (adult: 0.5 1.0 mg) intravenously
or sublingually; repeat, if necessary, in 10 mins.
Most faints are benign, particularly in young people.
In a patient > 50 years it should be regarded as serious.
In either age group, however, a physical examination is
necessary to delineate an obvious cause.
Postural hypotension
CAUSE
Rapid fall in blood pressure when moving from the supine to
upright position
SYMPTOMS
Similar to simple fainting, however this condition is related to
positioning
Loss of consciousness
Hypoglucemia
CAUSE
Drop in plasma glucose level central nervous system symptoms.
Diabetic patients taking insulin or oral hypoglycemics
Precipitating factors may include decreased/delayed food intake, heavy exercise
without increased food intake, errors in medication,
SIGNS AND SYMPTOMS
Rapid appearance of diaphoresis, decreased mental alertness, tremulousness, tachycardia,
and hunger.
Less common manifestations include headaches, confusion, unusual behaviour, focal
neurologic deficits, and eventually stupor and coma.
Loss of consciousness
Hypoglucemia
EMERGENCY TREATMENT
Steps 1, 2, 3, 4, 5; if the patient loses consciousness, implement Step 6
Step 7 If the patient is conscious, administer glucose or sugar by mouth (3 cubes)
Step 8 If the patient does not respond or is unconscious, glucagon (1mg) may be
administered subcutaneously, intramuscularly, or intravenously
Step 9 If there is no response, arrange to evacuate the patient to a hospital
Hyperventilation Syndrome
Asthmatic attack/ Bronchospasm
Airway obstruction
Respiratory distress
Hyperventilation syndrome
CAUSE
The most common cause is psycogenic hyperventilation: Patients with a history of
acute dyspnea and anxiety, often precipitated by personal or environmental
factors.
Hyperventilation may also result from hypoxia, salicylate toxicity, cerebrovascular
accident, exercise, sepsis, hepatic coma, trauma, metabolic acidosis.
SIGNS AND SYMPTOMS
Paresthesias of extremities and face are accompanied by chest tightness, dizziness,
and dryness of the mouth.
Severe hyperventilation causes cerebral vasoconstriction, occasionally leading to
syncope.
Respiratory distress
EMERGENCY TREATMENT
Steps 1, 2, 3, 4, 5; if the patient loses consciousness, implement Step 6
Step 7 Reassure the patient with sooting words, and provide calm surroundings
Consider and rule out hyperventilation secondary to medical conditions
Step 8 Patients with psychogenic hyperventilation may breath into a paper bag
Step 9 Diazepam (5-10mg) orally/IM only psycogenic hyperventilation
Step 10 Refer to an internist for a complete evaluation
Hyperventilation syndrome
Asthmatic attack/ Bronchospasm
CAUSE
Two clinical types: Extrinsic asthma (usually seen in adolescents/Young adults with
positive family history and other allergic conditions) and Intrinsic astma (older
patients with no allergies or family history, but other chronic lung diseases).
Precipitating factors: acute respiratory infections, allergic factors, environmental
factors, physical stimuli, aspirin sensitivity.
SIGNS AND SYMPTOMS
Difficulty with expiration and with a lesser extent with inspiration
Wheezing or stridor, congestion, respiratory depression, and airway edema
Respiratory distress
EMERGENCY TREATMENT
Steps 1, 2, 3, 4, 5; if the patient loses consciousness, implement Step 6
Step 7 Administer an aerosol bronchodilator (2 puffs)
Step 8 No response administer oxygen under pressure (2-4 L/min)
Step 9 No response and <50 , no hypertension/heart disease, pulse rate < 120
inject epinephrine (0.3-0.5 mL, 1:1000) subcutaneously every 30
mins up to 3 doses.
Step 10 If severe wheezing persists, status asthmaticus is likely.
Continue support of respiration with oxygen and evacuate to
hospital
Asthmatic attack/ Bronchospasm
Airway obstruction
CAUSE
The etiology is often obvious in an oral health-care setting.
SIGNS AND SYMPTOMS
The patient will often give the universal sign of choking:
distress-fingers around the neck.
Look for ineffective inspiratory efforts (the patient may
become agitated), often coupled with cianosis.
Respiratory distress
EMERGENCY TREATMENT
Steps 1, 2, 3, 4, 5, as applicable
Step 7 Ask the patient to speak
If it is posible, even in a whisper, the problem is laryngospasm or partial
rather tan complete airway obstruction. If the patient is able to cough do
not interfere in the effort to expel the foreign body. Be ready to provide
help immediately if obstruction becomes more complete.
If patient cannot speak proceed to Step 8
Step 8 Heimlich Maneuver
Step 9 If ventilation is unsuccesful or if the patient becomes unconscious,
contact EMS and continue attempting to ventilate with 2 quick breaths
and checking for a pulse.
Airway obstruction
Chest pain
Angina pectoris
Acute Myocardial Infarction (AMI)/
Heart attack
Angina pectoris
CAUSE
Temporary inability of the coronary arteries to supply the myocardium
with sufficient amount of oxygenated blood. The result is anoxemia
(total lack of oxygen) and pain.
Diseases: obstruction by fatty deposits (aterosclerosis).
SIGNS AND SYMPTOMS
During physical/emotional stress
Minimal to moderate substernal pain: appears quickly, may radiate to
shoulders, arms or jaw and usually subsides with rest and antianginal
medication.
Pain may be accompanied by pallor and sweating, lower BP, and slowed
pulse.
Chest pain
EMERGENCY TREATMENT
Steps 1, 2, 3, 4, 5; if the patient loses consciousness, implement Step 6
Step 7 Allow the patient to asume a comfortable position, and provide
a calm, quiet atmosphere.
Step 8 Administer nitroglycerin (0.3mg) sublingually; if the pain is not
relieved, this treatment may be repeated at 5-min intervals up
to 3 times.
Step 9 Initiate oxygen therapy by nasal prongs at a rate of 2 to 4 L/min.
Step 10 Refer to an internist for a complete evaluation
Angina pectoris
Acute Myocardial Infarction
(AMI)/Heart attak
CAUSE
Myocardial Infarction is ischemic necrosis of a localized area of the
myocardium due to the occlusion of a coronary artery.
Higher risk of MI: males, hypertension, smokers, diabetics,
hypercholesterolemia, family history of early coronary disease.
SIGNS AND SYMPTOMS
Patients usually will report onset of chest pain described as crushing,
squeezing, or heavy.
Pain similar to angina but more severe, last 10 min. or longer.
Pain may radiate into right arm, neck, jaw, shoulders or epigastric area.
Chest pain
EMERGENCY TREATMENT
Steps 1, 2, 3, 4, 5; if the patient loses consciousness, implement Step 6
Step 7 Allow patient to asume comfortable position, and provide a calm, quiet
atmosphere.
Step 8 Initiate oxygen therapy by nasal prongs at a rate of 2-4 L/min.
Step 9 Arrange for patients evacuation to a hospital immediately, as the risk of
ventricular fibrillation and sudden death is greatest in the first few hours
after MI.
Step 10 While waiting: Oxygen, aspirin, and nitroglycerin may be administered.
Morphine was classically used if nitroglycerin was not effective.
Acute Myocardial Infarction (AMI)
Urticaria/ Pruritus
Anaphylactic Shock
Epinephrine reaction
Allergic/ Drug reactions
Urticaria/ Pruritus
CAUSE
Allergy
SIGNS AND SYMPTOMS
Urticaria (red eruption on face, neck, hands, and arms),
pruritus (itching of these areas)
Allergic/ Drug reactions
EMERGENCY TREATMENT
Steps 1, 2, 3, 4, 5; if the patient loses consciousness, implement Step 6
Step 7 Withdraw drug in question (double-check patient record for any known
allergies)
Step 8 Administer Benadryl (diphenhydramine hydrochloride) 25-50 mg orally
Step 9 If reaction appears severe, activate EMS and administer epinephrine
0.3-0.5 ml
Step 10 As follow-up, prescribe antihistamines:
Diphenhydramine 25-50mg every 6-8 hours for 3 days
Urticaria/ Pruritus
Anaphylactic Shock
CAUSE
Circulatory and respiratory failure resulting from an immediate allergic reaction,
usually from 1 min. to 1 hour after exposure to an allergen (eg drug, drug overdoses).
Antigens react with immunoglobulin E antibodies fixed in tissue
enzymatic events with release of several chemical mediators of inflammation
critical damage to secondary sites , primarily smooth muscle and vascular
tissue.
Death may occur within minutes, usually as a direct result of respiratory obstruction
and/or circulatory collapse.
Allergic/ Drug reactions
SIGNS AND SYMPTOMS
Symptoms of generalized warmth with flushing and agitation.
Laryngeal edema may lead to a tightness in the throat and upper
respiratory distress or stridor.
Complete occlusion of the airway may result.
Lower airway obstruction is characterized by bronchospasm
(wheezing is a result of pulmonary edema).
Anaphylactic Shock
EMERGENCY TREATMENT
Steps 1, 2, 3, 4, 5; if the patient loses consciousness, implement Step 6
Step 7 Elevate the patients lower limbs and administer oxygen
Step 8 Administer adrenaline or epinephrine (1:1.000) subcutaneously or at base of
tongue. Adult dose: 0.3-0.5 mL or mg / Child dose: 0.01 mg/kg body weight.
Repeat after 5 minutes if necessary.
IV administration is preferred if patient has severe bronchospasm, airway
edema or hypotension.
Step 9 Antihistamines, such as diphenhydramine hydrochloride (50mg) should be
given IV or IM to counter effects of mediator release
Step10 Arrange for the patients evacuation to a hospital, and continue resuscitation
if the patient remains unconscious.
Anaphylactic Shock
Epinephrine reaction
CAUSE AND SYMPTOMS
Rapid elevation in blood pressure; epinephrine interactions with several groups
(tricyclic antidepressants and nonselective beta-adrenergic receptor blockers)
have been associated with hypertensive episodes.
EMERGENCY TREATMENT
Steps 1, 2, 3, 4, 5; if the patient loses consciousness, implement Step 6
Step 7 Administer oxygen, reassure patient, activate EMS if any other
signs or symptoms (eg arrhythmias) or if blood pressure does not
soon return to normal.
If trained and if patient is in seizure, administer anticonvulsant drug
as Valium (diazepam) 5-10 mg IV push, not exceed 5 mg/min.
Allergic/ Drug reactions
Stroke/ Cerebrovascular Accident
Seizure Disorders: Status Epilepticus
Panic Attacks
Altered sensation/ Changes in
affect
Stroke/ Cerebrovascular
Accident
CAUSE
A cerebrovascular accident (CVA) is an acute neurologic deficit resulting from an alteration of vascular
supply to brain tissue. It is ususally due to a primary thrombotic occlusion, or an embolic event, or in
hemorrhage from a ruptured vessel causing pressure or destruction of nerve cells.
Occurs in the presence of hypertension, cardiac disease,hytpercholesterolemia, diabetes mellitus, or
peripheral vascular disease.
SIGNS AND SYMPTOMS
The onset of neurological complaints may vary and includes a spectrum ranging from focal motor or
hypoesthesia (impairment of sensation and lessened tactile sensibility) to speech defects to profound
coma.
It may also be associated with vomiting, convulsions, or headache.
Stiffness of the neck may occur.
Altered sensation/ Changes in affect
EMERGENCY TREATMENT
Steps 1, 2, 3, 4, 5; if the patient loses consciousness, implement Step 6
Step 7 Ensure the patients airway is open, and mantain oxygen
therapy. Suction may required to remove saliva or mucous that may
obstruct the airway.
Step 8 Prepare for the patients evacuation to a hospital.
Step 9 While waiting for help, Steps 1, 2, 3, 4, 5; if the patient loses
consciousness, implement Step 6
Stroke/ Cerebrovascular Accident
Seizure / Status Epilepticus
CAUSE
Seizures result from paroxismal excessive neuronal discharge leading to generalized
manifestation.
Status epilepticus may be either continuous seizure activity or recurrent seizures
without return to a fully alert state.
Onset frequently occurs in childhood (idiopathic), or history of diabetes, thyroid
disease, renal disease, drug ingestin or alcoholism.
SIGNS AND SYMPTOMS
Sudden loss of consciousness followed by tonic stiffening and then tonic-clonic
activity.
Tongue biting or incontinence may occur.
Postictal confusion and amnesia for the period of seizure is common.
Altered sensation/ Changes in affect
EMERGENCY TREATMENT
Steps 1, 2, 3, 4, 5; if the patient loses consciousness, implement Step 6
Step 7 If the patient is in the dental chair leave there. The chair should be
lowered and fully reclined. Otherwise, lower the patient to the floor.
Step 8 Do not restrain, but guide the patient to avoid injury.
Step 9 Ensure adequate airway flow and oxygenation. Administer oxygen (5 to
6L/min) via a nasal canula. Respiratory depression is posible, so patients
respiration monitored
Step 10 As seizure activity subsides, allow the patient to sleep.
Mantain airway flow and place the patient in a lateral position.
Step 11 If seizure activity is prolonged (>5 mins.) 2.5 to 15mg diazepam IV and
transfer to hopital
Seizure / Status Epilepticus
Panic attacks
CAUSE
Acute anxiety
SYMPTOMS
Chest pain, hyperventilation, anxiety, nausea, vertigo (dizziness), paresthesia
(numbness or tingling in extremities), restlessness, trance-like state
EMERGENCY TREATMENT
Steps 1, 2, 3, 4, 5; if the patient loses consciousness, implement Step 6
Step 7 Do not administer oxygen if hyperventilation is part of the attack.
Step 8 If unsure, consider activating EMS
Altered sensation/ Changes in affect
The essential drugs and equipment
for the dental office (ADA 2010)
Suggested basic emergency drugs for
the general dental office (ADA 2010)
ADA 2010