EMERGENCIES IN DENTAL PRACTICE

Dentists must know how to recognize and

manage medical emergencies, even they may
be rare. Their professional skills and
equipment should enable them occasionally
to save patient’s life.
Patients suffering life-threatening
emergencies should be quickly transferred to
hospital, but cited traffic and the load on
ambulance services are so heavy that the
delay can be considerable. Under such
circumstances, measures taken by the dentist
may be critical.
 1-Sudden loss of consciousness
A- Fainting caused by transient hypotension and cerebral
ischemia.
B- Acute hypoglycaemia affects diabetic patients.
C- Circulatory collapse in patients on corticosteroid treatment.
D- myocardial infarction.
E- Anaphylactic collapse.
F- Cardiac arrest can follow myocardial infarction.
G- Strokes attacks patients are usually hypertensive and
middle-aged or elderly.
 1-Sudden loss of consciousness
A- Fainting caused by transient hypotension and
cerebral ischemia, is the most common cause of
sudden loss of consciousness in the dental surgery. The
anxiety, pain, injections, fatigue, and hunger are the
most predisposing factors to fainting.
The signs and symptoms of fainting are
premonitory dizziness, weakness or nausea, pale and
cold skin, initially slow and weak pulse becoming full,
and loss of consciousness.
 The management of a fainting attack accomplish by
lower the head after laying the patient flat to decrease the
cerebral hypoxia, loosen any tight clothing around the
neck, give a sweetened drink when consciousness has been
recovered, and if no recovery within a few minutes,
consider other causes of loss of consciousness.

In the regular fainters the preventive measures

helped by an anxiolytic, such as temazepam 5 mg orally on
the night before and again an hour before treatment, and
the patient must be accompanied by a responsible adult.
B- Acute hypoglycaemia affects diabetic patients after an
overdose of insulin or if prevented from eating at the expected
time by dental treatment. The signs and symptoms of it are
similar to those of a fainting, but little response to laying the
patient flat.
Before consciousness is lost, give glucose tablets or
powder, or hypostop (a gel containing glucose that provides
sufficient glucose absorbed through the oral mucosa to
combat declining consciousness). Ideally, if consciousness is
lost, give sterile intravenous glucose (up to 50 ml of a 50%
solution). If you do not interpret whether there is hypo or
hyperglycaemia you should give glucose.
C- Circulatory collapse in patients on corticosteroid
treatment: the response of patients on long-term
corticosteroid treatment to surgery is unpredictable, but
near fatal circulatory collapse can follow minor dental
extractions under anaesthesia in a patient taking as little as
5 mg of prednisone a day.

All patients who are taking systemic corticosteroids

are at risk. Adrenocortical function may possibly take up to
2 years to recover. skin preparations used liberally,
particularly for widespread eczema, can also lead to stress-
related collapse. Since large doses of corticosteroids given
for a short period are safe and can be life-saving.
 The management should be over protective by lay
the patient flat and raise the legs, given at least 200
mg hydrocortisone sodium succinate intravenously
(intramuscular route can be used if a vein cannot be
found but absorption is slower), and give the oxygen
and if necessary artificial ventilation, if the recovery
not achieved call the ambulance to transfer to
hospital.
The pallor, rapid weak or impalpable pulse, loss of
consciousness and rapidly falling blood pressure are
the main features of circulatory collapse. The general
anaesthesia, surgical or other trauma, and infections
or other stress are the main causes of corticosteroid-
related collapse.
D- myocardial infarction
characterized by severe chest pain,
but may suddenly lose
consciousness as a result of a
myocardial infarct.
E- Anaphylactic collapse which has typical features
of initial facial flushing, itching, paraesthesia or
cold extremities, facial oedema or urticaria,
bronchospasm, pallor going on to cyanosis, weak
pulse, deep fall in blood pressure, and loss of
consciousness. Death if treatment is delayed or
inappropriate. The common types of this condition
are the hypersensitivity reactions to penicillin and
aspirin.
 The management done by
1. lay the patient flat and raise the legs to
improve cerebral blood flow.
2. give 0.5-1 ml of 1:1000 adrenaline by
intramuscular injection and repeated every
15 minutes if necessary until the patient
responds,
3. give 10-20 mg chlorpheniramine slowly
intravenously,
4. give 200 mg of hydrocortisone sodium
succinate intravenously,
5. give oxygen if necessary, and call an
ambulance.
F- Cardiac arrest can follow myocardial infarction, or
the acute hypotension of an anaphylactic reaction or
of corticosteroid insufficiency. Otherwise, it may be
the result of an anaesthetic overdose or severe
hypotension. The signs and symptoms are sudden
loss of consciousness and absence of arterial pulses of
the carotid artery, anterior to sternocleidomastoid
muscle should be felt. The management start with put
the patient on a flat surface, and clear the airway and
keep it clear by extending the neck and holding the jaw
forward.
G- Strokes attacks patients are usually hypertensive and
middle-aged or elderly. The clinical picture varies with the
size and site of brain damage. Subarachnoid haemorrhage
from a ruptured berry aneurysm on the circle of Willis is
the main cause of stroke in a younger person.
It typically causes intense headache followed by
coma without localizing signs, loss of consciousness,
weakness of an arm and leg on one side, and drooping of
the side of the face. The management done by
maintained the airway, and call ambulance for transfer to
hospital.
2- Chest pain
A-Angina pectoris attacks patients with coronary atheroma
might have a first angina attack as a consequences of an
emotional response to dental treatment. However, more
patients have already had attacks and carry medication. Acute
chest pain due to myocardial ischaemia is the only symptom.
The symptoms are severe chest pain may radiated to
the left shoulder and arm. The management done by give the
patient his anti-anginal drug (usually 0.5 mg of glyceryl
trinitrate sublingually) or glycerol trinitrate spray (400 mg)
gives rapid relief. If there is no relief within 3 minute the
patient has probably had a myocardial infarct.
 B- Myocardial infarction
Several aspects of dentistry, particularly
apprehension, pain or the effect of drugs, might
contribute to make this accident more likely in a
susceptible patient. Some patients die within a few
minutes after the start of attack.
The severe crushing retrosternal, shallow
breathing, vomiting, and weak or irregular pulse are
the typical signs and symptoms. Pain can radiated to
the left shoulder or down the left arm but very
occasionally is felt only in the left jaw.
The management accomplish by put the patient in
a comfortable position that allows easy breathing,
do not lay flat if there is left ventricular failure and
pulmonary oedema. Call for intensive care
ambulance. Constantly reassure the patient and
give oxygen if possible. Give aspirin 150 mg by
mouth as soon as possible.
 3- Dyspnoea
A- Status asthmaticus caused is the loss of or forgetting
to bring a salbutamol inhaler, anxiety, infection or
exposure to a specific allergen. The signs are
breathlessness, inability to talk, rapid pulse and
cyanosis.
The management done by call an ambulance for
transfer to hospital , reassure the patient, do not lay
the patient flat, give the anti-asthmatic drugs such as
salbutamol by inhaler or better, by nebulizer, give
hydrocortisone sodium succinate 200 mg
intravenously, give oxygen, and if no response within
2-3 minutes, ideally give salbutamol 250 micrograms
by slow IV injection, if this injection not available
give adrenaline subcutaneously.
B- Left ventricular failure have typical sign of
extreme breathlessness, and it most likely to
be a consequence of a myocardial infarct but
can occasionally result from a severe
dysrhythmia, particularly in a patient who
has had a previous myocardial infarct. This
case managed by sitting the patient upright
and immediately call an intensive care
ambulance.
 4- Convulsions
Status epilepticus is happen if convulsions do not stop
within 15 minutes, or are rapidly repeated, and can
die from anoxia.
The management done by give 10 mg
intravenously diazepam to an adult patient, if venous
access cannot be obtained give 5 mg of intramuscular
midazolam ( absorption of intramuscular diazepam is
slow and unpredictable), repeat diazepam and
midazolam if no recovery within 5 minutes, maintain
the airway and give oxygen, and call an ambulance.
 5- Haemorrhage
Prolonged bleeding is usually due to traumatic
extractions. A major vessel is unlikely to be opened
during dental surgery and patients are unlikely to lose
any dangerous amount of blood if promptly managed.
Post-extraction bleeding is usually only an
emergency in the sense that the dentist may be woken up
at 3 o’clock in the morning by a frightened patient.
Occasionally, bleeding is due to an suspected
haemophilia or other haemorrhagic disorders.
 The management of prolonged dental
haemorrhage by reassure the patient, then clean
the mouth with swabs and locate the source of
bleeding, give adrenaline containing local
anaesthetic and remove ragged tissues, squeeze up
the socket edges and suture it.
When the bleeding has been controlled,
ask about the history and especially any family
history of prolonged bleeding. If bleeding is
continues despite suturing, transfer to hospital and
managed of any haemorrhagic defect.
 Ideally, tranexamic acid (500 mg in 5 ml, by
slow intravenous injection) should be given and
may be effective in a mild haemophilic while
awaiting transfer to hospital.
If bleeding is continues despite suturing,
transfer to hospital and managed of any
haemorrhagic defect. Ideally, tranexamic acid (500
mg in 5 ml, by slow intravenous injection) should
be given and may be effective in a mild
haemophilic while awaiting transfer to hospital.
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