MEDICAL EMERGENCIES

MADE BY: NITIN SHISHODIA B.D.S III YEAR

 CONTENTS
PREVENTION OF MEDICAL EMERGENCIES PREPARATION FOR EMERGENCIES EMERGENCY EQUIPMENT

EMERGENCY DRUGS
MANAGEMENT OF MEDICAL EMERGENCIES

INTRODUCTION
Dentistry is an invasive , surgical speciality that is often associated with high levels of patient anxiety .These factors combine to produce situation that may be conducive to medical emergencies , specially those that are induced or aggravated by stress . Also , pharmacological agents are used routinely in the dental office. All drugs whether L.A , antibiotics , sedatives , analgesics ,carry the potential for producing toxicity or allergy. The primary responsibilities of dentist in the areas of medical emergencies fall into areas of prevention , basic life support ,and procurement of help and transport.

PREVENTION OF MEDICAL EMERGENCIES

Prevention of medical emergencies can generally be accompolished ,as much as possible , by adequate history and and physical examination , medical consultation (if indicated) , and vigilant patient monitoring.

History and physical examination

A thorough knowledge of all existing medical conditions , physical or psychological ,that may predispose to patient to development of problem will prevent vast variety of emergency situation . This knowledge is gained through medical history and physical examination. The physical examination should include baseline vital signs (heart rate ,respiratory rate and character,and blood pressure in older children ), a thorough head and neck examination and observation of general appearance (gait, mental status, skin tone and color etc.)

Medical consultation
If any question arise regarding the management of a medically compromised child , it is higly desirable to contact patient physician for guidance.

 Patient monitoring
Patient monitoring involves the observation of physiologic parameters over time in order to detect any change and deal with it before a potentially dangerous situation develops .The dentist always monitor the general appearance of the patient , including the level of consciousness , level of comfort , muscle tone , color of the skin and mucosa , and respiratory pattern. The heart sound and breath sounds should be continuosly monitored using a precordial stethoscope in all patients undergoing conscious sedation . Whenever deep sedation or general anaesthesia is used , more sophisticated monitoring is essential.

PREPARATION FOR EMERGENCIES

Despite preventive measures , medical emergencies occasionally occur . The dental practitioner must be adequately prepared for such events . Preparation involves personal ,staff and office preparation .

Personel preparation
It should be possible to anticipate with some emergency situations that are most likely to occur in dental office and be well prepared to deal with them . Examples include syncope, hyperventilation ,seizures ,hypoglycemia, postural hypertension ,asthma ,allergic reactions ,and airway obstruction. Training in basic life support (cardiopulmonary resuscitation ; CPR) should be considered essential for any practicing health professional.

 Staff preparation
Official personnel should be trained in the recognition and management of common medical emergencies. It is desirable to require that all office staff members be certified in basic cardiac life support (CPR).

Offce preparation
Every dental office contains great deal of equipment and supplies . These essentials can be divided into emergency equipment and emergency drugs.

EMERGENCY EQUIPMENT
First of all ,oxygen must be readily available . An oxygen source capable of delivering greater than 90% oxygen at flows in excess of 5L/min for a minimum of 1hr must be available. Adequqte oxygenation must be ensured by the administration of supplemental oxygen . If the patient is breathing adequately spontaneouly, oxygen may be delivered by of face masks , nasal mask, or nasal prongs. A high- volume suction device is the third piece of equipment that is considered essential for the management of medical emergency. Other emergency equipment items that are desirable and recommended include syringes and needles ,the armamenterium for establishing intravenous line ;cricothyrotomy equipment ;oral and nasal airways ;a laryngoscope and endotracheal tubes.

EMERGENCY DRUGS
It is expected that pharmacological agents be available to definitely manage medical emergency that may be expected to arise as a direct result of any drug that is used to treat patients.

Drugs to manage allergy

EPENEPHRINE
Treatment of choice for life- threatening anaphylactic

reactions ,and for severe asthmatic reactions,and is basic cardiac life support drug. DOSAGE: 0.01mg/kg (o.1ml/kg of 1:10,000 I.V) , (0.01ml/kg of 1:000 I.M );May need to repeat after 5-10min. as needed.

DIPHENIHYDRAMINE (Benadryl) Used for allergic reactions of less severity and as an

adjuvant to epinephrine in severe allergic reactions . DOSAGE: I to3mg/kg ,I.V or I.M.

ANTICONVULSANT
DIAZEPAM
Used for the management of status epilepticus (recurrent seizures )

DOSAGE: <less than 5yrs: 0.3 mg/kg to a maximum dose not exceeding 0.25mg/kg to
a maximum of 0.75mg/kg total dose for episode , slow I.V or deep I.M Maximal dose 5mg/kg; >5yrs; 1mg/dose,slow I.V ; maximal dose,10mg. ADULTS :5 to 10mg/dose , slow I.V ,maximal total dose, 30mg.

BENZODIAZEPINE ANTAGONIST
FLUMAZENIL (Anexate,Romazicon)
Used to reverse the respiratory depression of other undesirable affects of several benzodiazepines ( e.g Diazepam etc. )

NARCOTIC ANTAGONIST
NALOXONE
Used to reverse respiratory depression or other undesirable affects of narcotic analgesic

STEROIDS

HYDROCORTISONE SODIUM SUCCINATE (Solu-cortef)

Used for management of acute adrenal insufficiency & as an adjuvant treatment to severe anaphylactic reaction or asthmatic attack.

DOSAGE: 0.2 to 1 mg/ml . Higher doses may be needed for acutely

life-threatening situations .

ANTIHYPOGLYCEMICS
50% DEXTROSE:
Used to raise serum glucose levels when there is loss of consciousness or obtundationas a result of hypoglycemia.

DOSAGE: 0.5 to 1 g/kg .(1 to 2 ml/kg ),I.V ,until patient regains

consciousness

GLUCAGON :
DOSAGE: If I.V access cannot be established, the hormone glucagon
may be used.
0.5 to 1 mg, I.M Maximal dose is 1 mg .

VASOPRESSORS
If I.V sedation techniques are being utilized, a drug to raise B.P in severe hypotension is advisable.

EPHEDRINE
Used to raise B.P and heart rate from shock levels.

DOSAGE: 0.5 mg/kg ,I.V or I.M.

METHOXAMINE
Used to raise B.P from shock levels. DOSAGE: 0.25 mg/kg I.M ,or 0.08 mg/kg , slow I.V

ANALGESIC
For acute conditions in which pain and anxiety may significantly worsen the clinical situation ,a narcotic analgesic may be indicated. This situation is primarily the case with myocardial infarction. Morphine ,meperidine (Demerol) etc. narcotics may be used.

OTHER DRUGS
Other drugs that are not injectable drugsbut might be included as part of emergency kit include :

1. a respiratory stimulant, such as aromatic ammonia inhalants,

2. sugar (to manage hypoglycemia in an awake patient) 3. a vasodilator such as nitroglycerine, and 4. a medihalar of metaprrotenol (metaprel), albuterol (ventolin , proventil) , isoetharine (bronkosol) to manage an asthmatic attack.

BACKUP MEDICAL ASSISTANCE

The final essential component of office preparation for medical emergencies involves securing backup medical assistance in advance. This involves having the current telephone no. of nearest rescue squad and emergency room facility conveniently displayed where they will be immediately available if needed.

MANAGEMENT OF MEDICAL EMERGENCIES

It includes :
Position Airway

Breathing
Circulation Definitive therapy

POSITION
For emergencies involving obtundation of consciousness or hypotension, the patient should be lying on his or her back with the feet raised slightly above the level of the heart ,increase return of pooled blood from the extremities , increase vital blood flow to the brain For medical emergencies in the conscious patient involving respiratory distress ( e.g. asthmatic attack ) or chest pain (angina) ,the semisitting postion is preffered by the patient.

AIRWAY

It includes establishment of patent , functioning airway, to prevent any rapid neurologic and cardiovascular deterioration in the absence of oxygen supply. The most common cause of airway obstructon is the tongue, when a patient is obtunded or unconscious.tongue becomes lax ,allowing the base of the tongue to fall back against posterior pharynx , thus blocking the airway. Extending the head on the neck and thrusting the jaw forward while opening the patient mouth is usually adequate to open the airway.

 If the airway is obstructed by a foreign body such as- cotton roll dental restoration etc. In conscios patient , the initial step is to deliver four sharp blows with the heel of the hend to the patient back , b/w scapula over the spine.It will rapidly raise intrathorasic pressure , causing a burst of air to be expelled through the larynx and dislodging the obstruction In the unconscious patient with obstructed airway, the patient is positioned supine (face up), the airway is positioned by tilting the head back and elevating the chin ,and and an is made to ventilate the patient manually utilizing either mouth to mouth resuscitation or a bag-valve mask system .This sequence is repeated until a patent airway is obtained or an invasive technique is deemed necessary.

 INVASIVE TECNIQUE
In children , total airway obstruction leads to cardiac arrest and brain dysfunction quite rapidly & is not tolerated for longer than 1min . Signs & symptoms of hypoxia ( cyanosis , arrhythmias )-then the invasive technique for opening of the airway must be used . The initial invasive tool includes direct laryngoscopy utilizing the laryngoscope, the larynx may be exposed so that any foreign body is removed under direct vision . Opening of airway using cricothyrotomy is the last method of airway control . The cricothyroid membrane is either incised or punchured to ventilate trachea with a flow of oxygen or allow respiration to be assisted .

 BREATHING
Once a patent airway is established ,adequate breathing is to be present . The chest should be observed for expansion and the nose and mouth observed for air flow during respiration by feeling and listening. If the patient is not breathing , rescue breathing should be initiated immediately. Rescue breathing may be accomplished by mouth to mouth or the bagvalve-mask technique. In mouth to mouth ventilation ,the efficacy is severely limited containing 15% to18% oxygen. Use of a positive pressure breathing system (bag-valve-mask) ,can deliver close to 100% oxygen ,is highly preferable.

 CIRCULATION
The most rapid convenient , and accurate method of assessing circulation is palpation of the carotid pulse .

The carotid artery is felt below the SCM in the neck.

The quality ,rate and rhythm of the pulses should be noted if the pulse is absent ,CPR should be initiated immediately. If the pulse is present , a more accurate assessment of cardiovascular state should be obtained by measuring B.P & H.R .

DEFINITIVE THERAPY
Only after the A , B & C of emergency management has been satisfied should be consider definitive drug therapy. If the emergency is acute and lifethreatening , especially if the cause is clear , the definitive therapy is indicated and essential. Some common medical emergencies for which definitive therapy is indicated are-

SYNCOPE

Vosodepressor syncope ,or simple faint is probably the most common cause of loss of consciousness. syncope is a maladaptive stress reaction is usually trigerred by anxiety. Breathing becomes irregular , the pupils dilate , and convulsive movement are often noted. The use of ammonia inhalant to stimulate patient may be of some of benefit. Oxygen may be administered ,airway ,breathing and circulation maintained, tight and constrictive clothing loosened.

 ALLERGIC REACTION
Allergy reactions involve hypersensitivity responses by the immune system to antigens that are recognized as foreign . The primary agents employed in pediatric dentistry that might provoke an allergic reaction are the penicillins , intravenous sedative agents , and ester type L.A . The anaphylactic reaction is mediated primarily by release of histamine . Skin involvement is the most common reaction and may range from mild erythematous rash, to urticaria , to angiodema. There may be constriction of bronchial smooth muscle producing respiratory distress. Management of allergic reaction include If symptoms are immediate and severe : EPINEPHRINE DIPHENHYDRAMINE If reaction is severe the patient is transported to hospital , & supplemental use of a corticosteroid is given

 SEIZURES
Management of seizure consist of gentle restraint and positioning of the patient in order to prevent self injury ,ensuring adequate ventilation and supportive care . Single seizure do not require drug therapy because they are self limiting . If the seizure continues to develop with little time between them ,a condition called status epilepticus has developed & this may be a life threatening medical emergency. This condition is best managed with I.V diazepam & transport should be arranged to take the patient to the hospital.

HYPERVENTILATION
Like syncope it is maladaptive anxiety reaction . More common in females . The patient is unware of the beginning of hyperventilate.The respiratory rate may increase to 25-30 breathes per minute, with an increase in tidal volume as well. The increase ventilation causes carbon-di-oxide to be eliminated from the blood .

 Management includes early recognition of patients anxiety . Reassurance ,patient rapport ,and calmly coaching the patient to breath slowly may be sufficient to stop the process. Oxygen should not be administered . This can be accompolished by having the patient to breath in the paperbag which causes the rebreathing of exhaled carbon-di-oxide containing air. Ocassionally, use of antianxiety agent ,(e.g I.V diazepam ) is helpful.

ASTHMA
The primary type of asthma that occurs in children is allergic or extrinsic asthma which is immunoglobulin IgE mediated. The asthma attack usually in this case is usually triggered by specific allergens such as pollen , dusts , and molds . If the patient begin to wheeze and develop any respiratory distress , they should be given oxygen and allowed to sit up .If they have medihaler , they should utilize it .

EPINEPHRINE should be injected S.C Early administration of corticosteroids may also be helpful in severe attacks.

DIABETES MELLITUS
It is a disorder involving poor insulin production. It is characterized by hyperglycemia if it untreated . D.M occuring in children is termed juvenile onset diabetes mellitus . The blood glucose level may be difficult to control . Sometimes condition known as diabetic ketoacidosis occurs , which may lead to coma and death if the patient is not treated. If a diabetic patient who is doing well and deterioration in the dental office the condition is far likely to be due to acute hypoglycemia ,or insulin shock . Management of hypoglycemia involves administration of glucose . In severe conditions I.V administration of 50% dextrose is given .

BIBLIOGRAPHY
PINKHAM CASSAMASSIMO FIELDS McTIGUE NOWAK MALAMED SF