EMERGENCY PREPAREDNESS

AND MEDICAL EMERGENCIES IN

DENTAL PRACTICE
- AN INTENSIVIST‘S PERSPECTIVE

Dr Vaidyanathan.R
Consultant anaesthesiologist and intensivist
CAUVERY HOSPITAL
MYSORE
 PREPAREDNESS
• Medical emergencies are rare in dental practice
though not uncommon.
• Studies show that anywhere from 19% to 44% of
dentists had a patient with a medical emergency in
any one year.

• Most of these complications,approximately 90%

were mild but 8% were considered to be serious.
• It was found that 35% of the patients were known to
have some underlying disease.
 contd
• OVER 50% of the emergencies were syncope with
hyperventilation the next most frequent at 7-8 %.

• Allergic reactions,angina pectoris/myocardial

infarction/ACS

• Cardiac arrest, postural hypotension, seizures,

bronchospasm and diabetic emergencies.

• ALL these constitute less than 1%.

PREVENTION IS BETTER
• Anticipate potential emergency and act
appropriately

• Prevention and preparedness is the key.

• Accomplished by a thorough medical

history appropriate alterations to dental
treatment as required
• Patients should be asked to bring their
medications to each dental appointment in
case of an emergency *( Eg nitrates,
salbutamol inhaler,etc)
 contd
• All dentists should have basic BLS skills.

• All personnel in dental OPD should preferably

be trained in BLS and know basic handling and
management of ABCs in emergencies.
• Emergency kit and drugs should be there in all
offices, clinics and procedure rooms

• Enroll and organise RRT IN bigger hospitals.

 Emergency kit and drugs
• Oxygen - 100%, Ambu bag (BMV), LMA
• Salbutamol – preferably inhalers.
• Epinephrine /ADRENALINE
• Sorbitrate tablets
• Acetylsalicylic acid (ASA) 160 or 325 mg)
• Hydrocortisone
• Diphenhydramine (inj.avil)
• Sugar cubes 1 or 2 cubes
• Atropine,Ephedrine,BZDs(midaz/loraz)morphine.
 RAPID RESPONSE TEAM(RRT)
• RRT is a designated group of healthcare personnel who can
be assembled quickly to deliver critical care expertise in
response to grave clinical deterioration of a patient located
outside a ICU

THE TEAM :
• Physician – senior resident / intensivist/ hospitalist
• Physician’s assistant
• Clinical nurse specialist/CCN
• Respiratory therapist
When to call ??
contd
contd
 The acute conditions…..
• SYNCOPAL ATTACK :

• Commonest. More than 50% of all emergencies.

• Predisposing factors– fear,anxiety,sight of blood.
• Often has a prodromal phase-light headedness,dizzy..
• Classical feature is bradycardia and hypotension.
• Self limiting.Rarely aggressive therapy indicated
• Stop the procedure. Supine position. Legs elevated.
Administer oxygen. Assess ABCs.
HYPERVENTILATION SYNDROME :
• Characterised by rapid and deep breathing often more
than 25 breaths per min
• Anxiety and fear common predisposing factors.
• All vital signs-HR,BP,RR often elevated.
• Tingling ,numbness , perioral anesthesia
• Symptoms of hypocalcemia-twitching,carpopedal
spasm,tremors .
• Treatment : upright position,loosen clothing,
rebreathing into cupped hands or paper bag.
 Anaphylaxis /severe allergy
• Patient experiences sinking feeling,intense itching,
flushing over face and chest.
• Rhintis,conjunctivitis,nasea,vomiting,cramps,palpitatio
ns,tachycardia,substernal tightness,wheezing and
dyspnea.
• Pale looking. Severe hypotension /cardiac arrest.
• Supine position. Assess ABCs
• TRY TO ESTABLISH IV LINE AND START IV
FLUIDS.
• INJ Avil 25 mg iv stat. inj hydrocortisone 100 mg iv
/im. Inj adrenaline 1in 10000 im/sc.
• Inj adrenaline 1 in 1000 iv in severe cases.
 Local anaesthetic overdose
• Patient experiences -
Agitation,confusion,excitement,talkativeness,slurred
speech, twitching and tremors.
• Head ache,visual disturbances and flushed feeling.
• Numbness of tongue,tingling and numbness of
perioral region.
• Drowsiness and rarely seizures.
• Reassurance,im midazolam 1 or 2 mg increase upto
5mg if seizures occur.
• CPR if cardiac arrest.
 ADRENALINE OVERDOSE

• Anxiety,fear, restlessness,throbbing
headache ,tremors
• Rapid and bounding pulse,perspirations.
• Elevated BP
• Treated by reassurance
• Semi sitting or upright position
• Midazolam 1 or 2 mg im.
 Acute severe asthma.
• Earlier called status astmaticus.
• Precipitation of severe acute bronchospasm in
known patients.
• Breathlessness,audible wheeze, rhonchi,cyanosis
in severe cases.
• Administer oxygen. Salbutamol inhalation 2
puffs repeated every 5-10 min.
• Inj hydrocortisone 100mg iv
• Inj adrenaline 1in 10000 sc/im in refractory
cases.
 Angina/chest pain/MI/ACS
• Sudden onset chest tightness ,heaviness ,chest pain or
breathlessness.
• Predisposed in elderly ,DM, HT,smoking or previous
history of MI/CVA/IHD
• Upright position, 100% oxygen,Aspirin 325 mg.
sorbitrate 10 mg sublingually.
• Shift to cardiac centre.
• Administer morphine and clopidogrel if available.
• CPR if cardiac arrest.
 Seizures.
• Predisposing factors are known
epileptics,pediatric patients, old CVA
• Local anaesthetic toxicity
• Assess ABCs.
• Supine position.
• Administer midazolam im 3-5mg or lorazepam
2-4mg
• Assess airway again and administer 100%
oxygen.
• Plan for shift
 Diabetic emergencies.
• Hypoglycemia ;
 Light headedness, tremors ,sweating drowsiness ,
rarely unresponsiveness.
 Prdisposed in elderly,starving ,OHA s
 Managed by sugar cubes orally repeated till
symptoms revert.
Hyperglycemia
 Predisposed in acute infections,poor diet compliance
and binge eating
 No specific signs except in DKA/NKHC
 Plan to shift.
 TIAS, CVAs
• Present similar to syncopal attack
• More prolonged phase of unresposiveness or
altered sensorium.
• Accompanied by slurred speech,weakness of
one or more limbs, deviation of angle of mouth.
• Rarely presents with seizures,abnormal
laboured breathing.
• Assess ABCs..
• Place in supine.Give 100% oxygen.
• Need to differentiate b/w bleed or embolism.
THANK YOU