MEDICAL

EMERGENCIES
IN DENTAL
PRACTICE

MODERATOR:
Dr. Vamshi

Presented by
Dr. Veena
1st yr pG
 CONTENTS
 Introduction
 Types of emergencies
o Prevention
o Preparation
o Management
 Summary
 Conclusion
 References
“When you prepare for an
emergency, the emergency ceases
to exist!”

Goldberger
 INTRODUCTION
* Medical emergencies can do occur in dental office. The dental office
environment is not immune to the occurrence of potential life
threatening situations.

* The overwhelming majority of emergencies encountered are

precipitated by the increased stress that is so often present in the
dental environment.

* Many factors can increase the likelihood of such incidents.

1) Increasing number of old persons seeking dental care,

2) Therapeutic advances in the medical profession,
3) Growing trend towards longer dental appointments and
4) Increasing use and administration of drugs in dentistry.
* The best way to handle an emergency is to be
prepared.

* Staff should be trained and frequently updated in

first aid and cardiopulmonary resuscitation
procedures.

* A written emergency plan should be available

Determination Of Medical Risk

American Society of
Anesthesiology
Physical Status Classification
System
ASA PHYSICAL STATUS CLASSIFICATION
The concept of ‘‘how healthy is the patient,’’ otherwise termed
‘‘risk assessment,’’ is key in determining the likelihood of
complications. The higher the ASA class, the more at-risk the
patient is both from a surgical and anesthetic perspective.

• ASA Class I. A normal healthy patient

• ASA Class II. A patient with mild systemic disease
• ASA Class III.A patient with severe systemic disease
• ASA Class IV. A patient with severe systemic disease that is a constant.
• ASA Class V- A moribund patient not expected to survive 24 hrs with or
without SURGERY
• ASA Class VI- Declared brain dead.
 MEDICAL
EMERGENCIES IN
DENTAL OFFICE
• Hyperventilation 29%
• Seizures 20%
• Hypoglycemia 14%
• Vasodepressor syncope 11%
• Postural hypotension 7%
• Asthma 7%
• Angina 5%
• Allergy 5%
Management Of Medical Emergencies
1. Prevention
2. Preparation
3. Basic life support (BLS)
4. Cardiopulmonary resuscitation (CPR)
5. Specific medical emergencies
COMPREHENSIVE MEDICAL HISTORY
•Thorough questionnaire
•Past medical history
•Familial disease history
•Dialogue history
•Psychological/ social status
•Diet
 BASIC LIFE SUPPORT

•Primary response: to all emergencies.

P-A-B-C-D
 P-Position
 A-Airway
 B-Breathing
 C-Circulation
 D-Defbrillation
 TYPES OF EMERGENCIES

• UNCONSCIOUSNESS / SYNCOPE
 Vasodepressor Syncope
 Postural/Orthostatic Hypotension
 Acute Adrenal Insufficiency
DIABETIC EMERGENCIES
 Hyperglycemia
 Hypoglycemia
• SEIZURES
• CEREBRO VASCULAR ACCEDENT
• RESPIRATORY EMERGENCIES
 Airway Obstruction
 Hyperventilation
 Asthma
• CARDIOVASCULAR EMERGENCIES
 Angina Pectoris
 Myocardial Infarction
• DRUG RELATED EMERGENCIES
 Overdose Reactions
 Allergies
• UNCONSCIOUSNESS / SYNCOPE

Vasodepressor Syncope
Postural/Orthostatic Hypotension
Acute Adrenal Insufficiency
 SYNCOPE
It is defined as sudden, transient loss of
consciousness that is usually secondary to period of
transient ischemia.
 Vasodepressor syncope
Pathophysiology
Anxiety/pain/stress

Release of epinephrine into the circulation

Peripheral pooling of blood

Decreased venous return

Decreased cardiac output

Decreased cerebral blood flow

SYNCOPE
 PREDISPOSING FACTORS

Nonpsychogenic factors
• Sitting in upright position or
standing Psychogenic factors
• Hunger • Fright
• Exhaustion • Anxiety
• Poor physical condition • Emotional stress
• Pain
• Hot, humid environment • Sight of blood or syringe
• Age between 16 to 35 years
• Males

 Webster-Merriam’s Medical Dictionary. 12th

ed. Baltimore:Williams;2011.“syncope”;p.348
 CLINICAL MANIFESTATIONS

Presyncope :
late :
Early : • Pupillary dilatation
• Feeling of warmth • Yawning
• Ashen gray skin tone • Hyperpnea
• Heavy perspiration • Coldness in hands and feet
• Fainting • Hypotension
• Bradycardia
• Nausea
• Visual disturbances
• Blood pressure • Dizziness
approximately at baseline • Loss of consciousness
• Tachycardia

Syncope
• Irregular gasping and jerky
breathing
• or it may cease entirely
(respiratory arrest/apnea)
• Dilated pupils
• Convulsive movements
• Bradycardia
• Low BP
• Weak and thready pulse
• Generalized muscle relaxation
Postsyncope :
• Pallor
• Nausea
• Weakness and Sweating
• Mental confusion and disorientation which
may persist for 24 hours
• Cerebral blood flow required for
maintaining consciousness is about 30ml
blood per 100 gm of brain tissue per minute.
• Normal value of cerebral blood flow per
minute is 50 to 55 ml per 100 gm per
minute.
• So when this decreases, syncope occurs.
 PREVENTION
• Via prevention of predisposing factors:
 Use of psychosedative drugs
 ingestion-alprazolam(4mg), diazepam(5mg)
i.m/i.v administration-butorphenol(1mg),
midazolam(5mg)
 inhalation-N2O+O2 (15%+85%)
MANAGEMENT
 Trendelenberg Position: supine position with brain and
heart at same level with feet elevated slightly (10 – 15
degrees).
 ABC: basic life support as needed.

 Definitive management:
-monitor vital signs
-administer aromatic ammonia
-administration of atropine(0.1g/ml)
 POSTURAL/ ORTHOSTATIC
HYPOTENSION

 Defined as disorder of the autonomic nervous

system in which syncope occurs when the patient
assumes an upright position.

 Infrequently associated with fear and anxiety.

 PATHOLOGY
Pt attains upright
position

SBP falls =<60mm of Hg

due to ANS response
failure

Cerebral blood
flow<critical level

Loss of consciousness
CLINICAL CRITERIA FOR
ETIOLOGY
POSTURAL HYPOTENSION
 Drugs
• Symptoms develop on
Prolonged period of
standing without any prodromal recumbency /
syndromes convalescence
Late stage
• Decrease in standing systolic
pregnancy
BP atleast 25mm Hg  Varicosities
• Decrease in standing diastolic  Addison’s Disease
 Severe exhaustion
BP atleast 10mm Hg.
Shy-Drager
• No postrecovery signs and Syndrome
symptoms
Dental therapy considerations:
• Patients should be cautioned against rising
too rapidly from supine or semisupine
position.
• Patient should be slowly returned to erect
position at conclusion of therapy.
 ACUTE ADRENAL INSUFFICIENCY
Syncope caused due to lack of an adrenaline response
in medullary deficient patients resulting from:-

• Sudden supplement withdrawal in Addison’s disease pts.

Cause1

• Stress, either physiological or psychological.

Cause2

• Bilateral adrenalectomy pts.

Cause3

• Trauma/thrombosis/ tumour of adrenals

Cause4
PATHOPHYSIOLOGY
 RULE OF TWO:

PREDISPOSING
• In a dose of 20 mg or more of
FACTORS: cortisone or its equivalent daily
 Addison’s disease • Via the oral or parentral route for a
 Secondary continuous period of 2 weeks or
insufficiency longer
 Stress • Within 2 years of dental therapy
CLINICAL MANIFESTATIONS
• Weakness and fatigue
• Anorexia
• Weight loss
• Hypotension
• Hypoglycemia
• Nausea, vomiting
• Syncope
• Confusion(marked most notably)
DENTAL THERAPY CONSIDERATIONS

• Glucocorticosteroid coverage
• With milder stress like single dental extraction, use
double dose daily.
• In moderate stress like surgery under local anaesthesia,
several dental extractions, use Hydrocortisone 100mg or
prednisolone 20 mg or Dexamethasone 4 mg daily.
• Severe stress like in severe trauma use Hydrocortisone
200mg, or prednisolone 40 mg or Dexamethasone 8 mg
daily.
DIABETIC EMERGENCIES
Hyperglycemia
Hypoglycemia
DIABETIC EMERGENCIES
 Diabetes is the most common endocrine disease. Approximately 135
million individuals worldwide have diabetes mellitus.

 Diabetes mellitus (DM) is a disease of glucose,fat, and protein

metabolism resulting from impaired insulin secretion, varying degrees of
insulin resistance, or both.
Stress increases body resistance to insulin and so patients may develop
hyperglycemia during Treatment

 Although HYPERGLYCEMIA does not itself usually lead to an acute,

life threatening emergency, if left untreated it may progress to diabetic
ketoacidosis and subsequent diabetic coma, both of which are life
threatening.

A dentist in general practice is much more likely to encounter

hypoglycemia than hyperglycemia since the latter has a much slower
onset.
Hyperglycemia
Clinical features:

• Florid face, dry, warm skin

• Kussmaul’s respiration
• Fruity odour
• Rapid, weak pulse
• normal to low Blood pressure
• Rapid Heart rate.
Management of hyperglycemic patient
(unconscious patient)

• Terminate dental procedure

• Position the patient
• BLS
• Summon medical assistance
• IV infusion (5% dextrose and water)
• administer oxygen
• If diagnosis in doubt, administer glucose paste
• Transport to hospital
HYPOGLYCEMIA
 Hypoglycemia is a clinical syndrome in which low serum
(or plasma)glucose levels lead to symptoms of sympatho-
adrenal activation
Common symptoms
 PATHOPHYSIOLOGY
 In patients receiving injectable insulin therapy who
may lose consiousness within minutes after insulin
administration

 Failed or inadequate meal

DIAGNOSIS
•Pallor, sweating

•Tremor/ circumoral tingling

Cerebrovascular accedent
 CEREBROVASCULAR ACCEDENT
Defined as any vascular injury that reduces cerebral blood
flow to a specific region of the brain, causing neurologic
Impairment.

Predisposing factors:
 Consistently elevated blood
pressure is a major risk factor
 Diabetes mellitus
 Cardiac enlargement
 Hypercholesterolemia
 Use of oral contraceptives
 Cigarette smoking
Diagnosis:
Hemiplegia
Weakness
Hemianaesthesia.
 Prevention:
Medical history questionnaire
Dialogue history
Physical examination

Dental therapy considerations:

 Length of time elapsed since the CVA – should not
undergo elective dental care within 6 months of the
episode
 Minimization of stress – morning appointments,
effective pain control, psychosedation during
treatment
 Assessment of bleeding – most of CVA patients
are on antiplatelet or anticoagulant therapy
Seizures
 SEIZURES
• It is a paroxysmal disorder of cerebral function characterized by
an attack, involving changes in the state of consciousness,
motor activity or sensory phenomena.
• Usually sudden in onset and of brief duration.
• EPILEPSY: “A chronic disorder in which nerve cell activity in the
brain is disturbed, causing seizures”.
 PATHOPHYSIOLOGY
 Toxic reaction to drugs

Infection

Fever

Anxiety

pain
Common symptoms of seizures
PREVENTION
 If a patient is known epileptic, make sure he/she has taken their
regular dose of anti-convulsant on the day of treatment.

 Instruct him/her to alert you as the aura of the impending seizure

manifests itself.

 Keep life support equipments ready, in case of an emergency

status epilepticus.
MANAGEMENT

 Self limiting emergency

 Position: supine with patient placed on flat surfaces.
 Remove dangerous objects from the mouth and around the
patient.(ex.sharp instruments, needles, etc.)
 Loosen any tight clothing.
 Avoid restraining the patient.
 In case the ictus fails to subside within a maximum of 10 minutes,
declare status epilepticus and proceed with definitive care.
DEFINITIVE TREATMENT

 Diazepam – 10 mg i.v. , (2mg/min) repeat every 10 minutes.

 Phenobarbitone – 100-200 mg/min, i.v.
 Carbamazepine
 Phenytoin
RESPIRATORY
EMERGENCIES
• RESPIRATORY
EMERGENCIES

Airway Obstruction
Hyperventilation
Asthma
 AIRWAY OBSTRUCTION
• May occur due to:
 Pathology in the airway
 Dental instruments
 Tongue

• Patient demonstrates
symptoms ranging from
coughing, gagging to
choking & gasping with
panic.

• Aspired object may pass into

the trachea or the Aspirated:
oesophagus Right mainstem bronchus
 PREVENTION
 Rubber dam
 Oral packing
 Chair position
 Magill’s intubation forceps
Visible objects if
assistant is present

If assistant is not
present
 MANAGEMENT
Re-establishment of
airway:
Non-invasive procedures
 Forceful coughing
 Back blows
 Heimlich maneuver
 Chest thrust
 Finger sweeps
Surgical approach:
Tracheostomy
Cricothyrotomy
HYPERVENTILATION:
• Excessive rate and depth of respiration leading to abnormal loss of
carbon dioxide from the blood primarily predisposed to stress and
anxiety.

• Characterized by:
 Rapid short strained breaths
 Cold sweats
 Palpitations
 Dizziness
 Chest muscle fatigue
 PREVENTION
Reduce patient’s stress and
anxiousness by any means.

 The operator should stay calm and also

make the patient be relaxed.

Exhaled air is inhaled-in again using a

paper bag.

The point of breathing into a bag is to

“rebreathe” your exhaled CO2 to bring the
body back to a normal state.
MANAGEMENT

Position pt UPRIGHT comfortably

Reassure pt & stabilise vitals

Remove dental materials/instruments

from pt’s mouth

Re-establish O2:CO2 ratio by inhalation

of exhaled air(85%:15%)

Check vitals & patient status again

Resume treatment procedure

 ASTHMA
• A clinical state of hyper reactivity of the
tracheobronchial tree, characterized by recurrent
paroxysms of dyspnea and wheezing

• In diagnosed pts, not an emergency.

 MANAGEMENT
Recognise symptoms

Stop dental procedure

Position pt upright or bending forwards with arms

straight ahead

Administer bronchodilator

Episode terminates?

YES NO

Continue dental procedure Declare status asthmaticus

Summon EMS
CARDIOVASCULA
R
EMERGENCIES
 ANGINA PECTORIS
MYOCARDIAL INFARCTION
 Heart recieves blood via coronaries

Coronaries narrow down due to

cholesterol

Reduced nutrition to respective cardiac

muscle

Treatment anxiety leads to palpitations

Greater oxygen requirements for greater

pumping

Acute Coronary
Syndrome(ACS)

ANGINA MYOCARDIAL
PECTORIS INFARCTION
 ANGINA PECTORIS
• Definition- “A condition marked by severe pain in the chest, often also
spreading to the shoulders, arms, and neck, owing to an indequate blood
supply to the heart.”
• Types:
 Stable (classic or exertional)
 Variant (prinzmetal , vasospastic)
 Unstable (crescendo, acute coronary insufficiency)

Webster-Merriam’s Medical Dictionary. 12th ed. Baltimore:Williams;2011. “Angina Pectoris”; p73

MANAGEMENT
 Recognize problem (chest pain – angina attack)
Discontinue dental treatment
 Activate office emergency team
P – Position, patient comfortably usually upright A → B → C –
Assess and perform BLS

D – definitive management

HISTORY OF ANGINA PRESENT NO HISTORY OF ANGINA

Administer vasodilator and O2 Activate EMS
Transmucosal nitroglycerine spray O2 and nitroglycerine
Or sublingual nitroglycerine tablet Monitor and record
0.3 – 0.6 mg for every 5 min (3 doses)

IF PAIN RESOLVES: IF PAIN DOES NOT RESOLVES:

continue with dental  summon medical care
procedure  Administer aspirin Continue
to monitor and record vital
signs
 MYOCARDIAL INFARCTION
• DEFINITION- “A clinical syndrome caused by
deficient coronary arterial blood supply resulting
in ischaemia to a region of the myocardium and
causing cellular death and necrosis.”

• Predisposing Factors:
– Atherosclerosis and coronary artery disease
– Coronary thrombosis, occlusion and spasm
– Males
– 5th and 6th decades of life
– Undue stress

Clinical features:
 Levine’s sign

Webster-Merriam’s Medical Dictionary. 12th ed. Baltimore:Williams;2011. “Myocardial Infarction”; p197

 DENTAL CONSIDERATIONS
Avoid overstressing the patient
Supplemental oxygen during the treatment
Pain control during therapy (appropriate use of
local anesthesia)
Psychosedation
Elective dental care is avoided until atleast 6
months after MI
 Inferior alveolar and PSA nerve blocks should be
avoided due to high risk of hemorrhage.
 MANAGEMENT

• Protocol common for both ACS outcomes

• NOTE: In a patient experiencing chest
pain for the very first time, summon
medical assistance immediately before
any self-support measures.
• Thereafter, continue with immediate
emergency protocol as with Angina
pectoris.
PORTABLE AUTOMATIC EXTERNAL DEFIBRILLATOR (AED)
 CASE REPORT
45 year old obese male with history of coronary artery disease
and heavy smoking.He is undergoing general restorative
procedures. Patient is given 4 carpules of 2% lidocaine with
epinephrine for bilateral mandibular blocks. During the
procedure, patient begins to complain of chest tightness and
Shortness Of Breath. He also reports pain radiating to his left side of
jaw and arm.

DIAGNOSIS ?

PREVENTION ?

MANAGEMENT ?
 Angina Pectoris
 Place patient in a comfortable semi-inclining position.
 Ascertain that the airway is open & breathing is unlabored.
 Administer 100% Oxygen at 4 liters via nasal cannula.
 Monitor vital signs: Blood pressure, pulse, & respiration.
 Administer Nitroglycerin sublingually (0.4 mg).
 Repeat Nitroglycerin every 5 minutes, until pain resolves or
blood pressure becomes <90, or a maximum of 3 doses.
IF PAIN DOES NOT RESOLVE, SUSPECT MYOCARDIAL
INFARCTION
 Administer Morphine Sulfate 2-5mg IV. if pain persists after 3
doses of NTG.
 Transfer to hospital
Case (Continued)
Patient is now on 100% oxygen and has been given 3
doses of Nitroglycerin in 5 minute intervals. At this
time, patient loses consciousness and becomes
unresponsive.

Diagnosis ?

Management ?
 Myocardial Infarction
ABC now changed to CAB sequence
Chain of Survival”:
1) Immediate recognition of cardiac arrest and
activation of Emergency response system
2) Early CPR with emphasis on chest
compressions
3)Rapid defibrillation
4)Effective advanced life support
5)Integrated post-cardiac arrest care
DRUG RELATED

EMERGENCIES
 DRUG OVERDOSE REACTIONS
ALLERGY
 DRUG OVERDOSE REACTIONS
An overdose is when a person ingests or takes in more than normal of
recommended or prescribed amount of drugs. It can be accidental or
intentional.
 In a dental practice, most common overdosage is by local anesthesia.
• Predisposing factors for over dosage:
 Pt age/body wt
 Route of administration
 Presence of vasoconstrictor
 Type of local anaesthetic

• Drug dosage formulation vital

 CLINICAL MANIFESTATIONS
• Confusion, talkativeness, blurred speech
• Muscular twitching, facial tremor
• Headache, tinnitus
• Drowsiness, disorientation
• Elevated BP, Heart rate and respiratory
rate
• If uncontrolled, generalised tonic clonic
seizures occurs.
 MANAGEMENT
• Administer basic life support
• 100% oxygen, anticonvulsants
• Allow recovery to occur
• In case of continuation of symptoms,
summon EMS.
 ALLERGY
• DEFINITION- “A hypersensitive state of skin and various
mucosae acquired through exposure to a particular allergen,
reexposure to which produces a heightened emergent
capacity to react”
• Occuring via expression of IgE in
response to allergen
Anaphylaxis is a Type 1 hypersensitivity reaction involving
IgE to which free antigen binds leading to the release of
vasoactive peptides and histamine.
COMMON ALLERGENS IN DENTISTRY
Antibiotics – Penicillins, Cephalosporins,Tetracyclines,
Sulfonamides*
Analgesics - Acetylsalicylic acid (aspirin), Nonsteroidal anti-
inflammatory drugs
Local Anesthetics – Esters - Procaine, Propoxycaine,
Benzocaine, Tetracaine
Preservatives - Parabens (methylparaben),
Bisulfites, metasulfites,
Other Allergens - Acrylic monomer (methyl methacrylate),
Latex
 PREVENTION:
 Always take a thorough allergy history especially
penicillin.

 Do not risk exposing a patient to a possible

allergen, Believe your patient.

 Have an up to date EMERGENCY TROLLY in the

clinic
 MANAGEMENT
• Reassure pt.
• Initiate basic life support as needed.
• Administer antihistamines (diphenhydramine
50mg), epinephrine 0.123-0.3ml of 1:1000
i.m /s.c
• Monitor vitals regularly.
EMERGENCY DRUG KIT
 CONCLUSION

 As the saying goes, “PREVENTION IS BETTER THAN

CURE”.
 ALWAYS BE PREPARED.
 Prompt recognition and efficient management of
medical emergencies by a well-prepared dental team that
can increase the likelihood of a safe & a satisfactory
outcome.
 Basic life support training – A MUST.
 REFERENCES

• Medical emergencies in Dental Practice –Malamed

• Emergencies in Dental Practice- McCarthy
• Management of Medically Compromised Patients –
DCNA Oct, 2008
• Oral medicine – Tyldesley’s
• Oral and Maxillofacial surgery- Daniel Laskin