Medical emergencies in

dentistry
Presented by
R.Aysha sulthana
CRRI

Introduction
Various emergency conditions arises
in a dental operatory
Basic method to avoid such condition
is prevention
Prevention : Complete information
on the past medical history, thorough
clinical examination and physical
examination

Classification of medical
emergency

Syncope
Hypoglycemia
Epileptic episode
Angina
Myocardial infarct
Anesthetic overdose
Drug allergy anaphylaxis
Asthma

Continued..

Respiratory distress
Postural hypotension
Adrenal crisis
Thyroid dysfunction
Drug overdose reaction
Postural hypotension
Hyperventilation
Obstruction due to foreign body

Precautions in dental office

BLS certification
ACLS certification
Emergency drug kit
Preparation of dental surgeon and
teaching various methods to tackle
such conditions given prime
importance

ASA classification of
physical status
Class 1 : Healthy patients with no
systemic disease
Class 2 : mild systemic disease with no
limits on activity
Class 3 : severe systemic disease that
limits activity
Class 4 : incapacitating systemic disease
that is life threatening
Class 5 : moribund and emergency of
any kind E

What is Anxiety recognition

and stress reduction protocol ?
Recognize patients anxiety level
Premedication or sedation
Minimize waiting time and
appointment length
Adequate pain control
Monitor vital signs
Medical counsel if required

Premedication drugs
DRUG

RECOMMENDED DOSAGE
FOR
ADULTS

ALPRAZOLAM

4 mg /day

DIAZEPAM

2-10 mg

FLURAZEPAM

15-30 mg

TRIAZOLAM

125-250 mic g

ESZOPICLONE

2-3 mg

ZALEPLON

5-10 mg

ZOLPIDEM

10 mg

High risk category

Prosthetic cardiac valves

Bacterial endocarditis
Cyanotic Congenital heart disease
Surgically constructed systemic
pulmonary shunts

Moderate risk category

Acquired valvular dysfunction
Other congenital cardiac
malformations
Hypertrophic cardiac myopathy
Mitral valve prolapse

Negligible risk category

Isolated atrial septal defect
Surgical repair of ASD,VSD, patent
ductus arteriosus
Mitral valve prolapse
Heart murmurs
Rheumatic heart disease
Cardiac pacemakers and implanted
defibrillators

What is basic life support?

Advanced cardiovascular life

support (ACLS)

Critical or essential emergency

drugs primary
category

Generic
drug

Allergy
epinephrine
-anaphylaxis

Alternative Quantity

Availability

none

1:1000
( 1mg/ml)

1 preloaded
syringe +
1*3 ml
ampules

Allergyhistamine
blocker

chlorphenira diphenyrami 3 * 1 ml
mine
ne
ampules

Oxygen

Oxygen

Vasodilator

nitroglycerin Nitrostat
e
sublingual
tablets

1 E cylinder
1 metered
spray bottle

Bronchodilat Albuterol
or

metaprotere 1 metered
nol
dose inhaler

antihypogly

Insta

sugar

10 mg/ml

1 bottle

0.4mg/mete
red dose
Metered
aerosol
inhaler

critical drugs continued..

Oxygen
delivery
system

Positive
pressure
and demand
valve
Pocket mask

Automated
electronic
defibrillator
Syringes for
drug
administrati
on

Oxygen
Minimum 1
delivery
large per
system with adult
bag valve
mask device
1 AED

Plastic
disposable
syringes
with needles

3*2 ml
syringes
with needles
for
parenteral
drug
administrati
on

Secondary - non critical

drugs
Anti
convulsant

Midazolam

Diazepam

1 * 5 ml vial

5 mg/ml

Analgesic

Morphine
sulphate

Merperidine

3*1 ml
ampule

10 mg/ml

Vasopressor

Phenyl
ephrine

Glucagon

3* 1 ml
ampule

10 mg/ml

1 vial

50 ml
ampule

Anti
50 /hypoglycemi dextrose
c
Corticosteroi Hydro
d
cortisone
sodium
succinate

Dexamethas 2 *2 ml mix
one
o-vial

50 mg/ml

Anti
hypertensiv
e

Propanalol

100 mg/ml

Esmolol

2 * 100
mg/ml vial

antidotal drugs
Opioid
antagonist

2 * 1 ml
ampules

0.4 mg/ml

Benzodiazep Flumazenil
ine
antagonist

1 * 10 ml
vials

0.1 mg/ml

Anticholiner
gic toxicity

3 * 2 ml
ampules

1 ml

Anti
emergence
delirium

Naloxone

Physostigmi
ne

Nalbuphine

Advance cardiac life support

drugs
Cardiac
arrest

Epinephrine

3 * 10 ml
preloaded
syringe

1:10,000

Analgesic

Morphine
sulphate

N2O-O2

3 * 1 ml
ampules

100 mg/ml

Antidysrhyth Lidocaine
mic

Procinamide

1 preloaded
syringe , 2*
5 ml
ampules

100
mg/syringe

Symptomati
c
bradycardia

Isoprotereno 2* 10 ml
l
syringes

Atropine

Paroxysmal
Verampamil
supraventric
ular
tachycardia

2 * 4 ml
ampules

1.0 mg/10ml

2.5 mg/ml

Syncope
Sudden, transient loss of consciousness
that occurs secondary to the period of
cerebral ischemia
Freight
Anxiety
Receipt of unpleasant news
Emotional stress
Receipt of unwelcome news
Pain ( sudden and unexpected)
Sight of blood surgical / dental instruments

Non psychogenic factors

Erect sitting
Hunger from dieting
Exhaustion
Poor physical condition
Hot humid crowded environment
Male gender
16 and 35 years of age

Assess consciousness
Activate office emergency system
Position
ABC
Perform additional procedures :
administration of aromatic ammonia
valporate, atropine if bradycardia persists
Postpone dental treatment
Identify causes
If delayed recover then activate EMS

Postural hypotension

Prolonged erect sitting

Recumbency or convalescene for longer time
Late stage pregnancy
Advance stage
Inadequate postural reflex
Advanced age
Venous defects in legs
Physical exhaustion and starvation
Recovery from sympathectomy
Addison disease
Chronic postural hypotension

Management
Positioning with feet elevated slightly
ABC
Definitive care : administer o 2 and
monitor vital signs
If recovery : slow repositioning of chair
Delayed recovery : activate EMS
Continous BLS as needed and
discharge patient

Diabetes melliteus
hyperglycemia and
hypoglycemia

High levels of blood sugar due to

defects in insulin production,action or
both
Type 1 diabetes melliteus
Type 2 diabetes melliteus

ASA PHYSICAL STATUS

TREATMENT
CONSIDERATION

II

Eat normal breakfast and take

usual insulin dose in the morning
Avoid missing meals before and
after surgery
If missing meal is unavoidable
consult physician or decrease
dose by half

III

Monitor blood glucose levels more

frequently for several days
following surgery and modify
insulin accordingly
Consider medical consultation

IV

Consult physician before

treatment

Antibiotic prophylaxis

Management
Lack of response to sensory stimulation by
dental treatment
Discontinue dental treatment and activate
office emergency team
Supine position with legs elevated
Assess ABC
D definitive care : summon EMS
Establish IV infusion, 5 percent dextrose or
of normal saline
Administer o2
Transport to hospital

 Antibiotic coverage post surgical

treatment
Stress reduction protocol
Monitoring of the surgical site

Thyroid gland dysfunction

T3 ,t4 and calcitonin regulation of
biochemical activity of body tissues
Prevention : medical history ,thorough
clinical examination
Clincal considerations : euthyroid
patients with normal hormone levels
can be managed normally
Hypothyroid : avoidance of CNS
depressants ( opioids, sedatives and
hypnotics)

 Hyperthyroid : avoidance of atropine

and vasoconstrictor. Least
concentrated solution preferred
1:200000 . Smallest effective volume
of anesthetic and
vasodepressor,aspiration prior to
every injection
Evaluation of cardiovascular disease

Management
Supine position with feet elevated
Definitive management : activate EMS if
recovery is not immediate establish IV access
Hypothyroidism : iv doses of thyroid hormone
for several days
Thyrotoxicosis : administer larger doses of
antithyroid drugs
Additional therapy : propanolol ,
glucocorticoids
Administer O2
Discharge and hospitalise patient

Foreign body airway

obstruction

What is adrenal crisis?

Lack of glucocorticosteroid hormone
Sudden withdrawal of steroid hormone
suffering from primary adrenal insufficiency
Temporary insufficiency by cortical
suppression
Stress physiologic or psychologic
Bilateral adrenalectomy
Sudden destruction of pituitary gland
Injury to adrenal gland

Prevention
Rheumatic fever, asthma , TB,
emphysema.other lung disease, arthiritis ,
rheumatism
Allergy to drug ,food ,medication and latex
RULE OF TWO : in a dose of 20 mg or
more of cortisone or its equivalent via oral
or parenteral route of two weeks no longer
Within 2 years of dental therapy

Management
If conscious terminate dental treatment
Position patient comfortably if
asymptomatic
Supine with legs elevated slightly
Assess ABC
D definitive care
Monitor vital sign
Medical assistance
Admnister glucocorticosteroid

Hyperventilation
Ventilation in excess
Increase in frequency or depth of
respiration or both
Common cause : extreme anxiety
Prevention : by prompt recognition
Vital signs
Stress reduction protocol

Management
Position the patient usually upright
ABC
D definitive care : remove dental materials
from patient mouth and calm patient
Correct respiratory alkalosis : breathing of
3 percent co2 and 97 percent o2
Continue dental care if doctor and patient
agrees
Discharge patient

Asthma
Chronic inflammatory disorder
characterised by reversible
obstruction of the airways
Allergens
Food and drugs
Type 1 hypersensitivity reactions
Psychological and physiological
causes

 Stess reduction protocol

Contraindication of barbiturates and
opioids
Inhalation anesthetics like ether
cause irritation
Careful prescription of analgesics
Sensitive to bisulphides LA is
contraindicated

management

Recognition of problem
Discontinue treatment
Activate office emergency team
Upright with arms thrown forward
ABC
D administer o2
Sedatives strictly contraindicated ,IM
Diazepam to decrease anxiety

Drugs prescribed

Administer bronchodilator by inhalation

Salmeterol
Aminophylline
Theophylline
Metaproterenol
Albuterol
Epinephrine
levabuterol

Heart failure and acute

pulmonary edema
Inability of heart to supply sufficient
oxygenated blood for metabolic needs
Increase in the workload high blood
pressure
Coronary disease and acute
myocardial infarction
Pregnancy , anemia , hyperthyroidism,
pagets disease
Psychological and climatic stress

 ASA I : No dyspnoea and fatigue with normal

exertion. No special dental modification
ASA II : mild dyspnoea and fatigue during
exertion. Stress reduction protocol should be
considered
ASA III : dyspnoea and fatigue with normal
activities. Medical consultation, stress reduction
protocol and other treatment modification
ASA IV : dyspnoea ,undue fatigue, orthopnoea at
all times. Only elective procedures- dental
emergencies managed with medication. Physical
intervention only in hospital dental clinics

Acute pulmonary edema

All signs and symptoms of heart
failure
Moist rales at lungs
Tachypnoea
Cyanosis
Frothy pink sputum
Increased anxiety dyspnoea at rest

Management
Assess presence of consciousness and any difficulty in
breathing
Position conscious patient in any comfortable position
usually upright
Activate office emergency team
ABC assessment
Definitive treatment : administer O2
Monitor vital signs
Alleviate symptoms of respiratory distress
Perform bloodless phlebotomy
Administer vasodilator eg: nitroglycerine
Alleviate apprehension eg: morphine
Discharge patient and modify subsequent dental
treatment

Seizures
PARTIAL SEIZURE

GENERALISED SEIZURE

SIMPLE PARTIAL

ABSENCE OF SEIZURE ( TRUE

PETITMAL)

COMPLEX PARTIAL

MYOCLONIC SEIZURES

PARTIAL SEIZURE EVOLVING TO

GENERALISED

TONIC CLONIC SEIZURES

TONIC CLONIC

UNCLASSIFIED EPILEPTIC SEIZURE

CAUSE

Congenital abnormalities
Perinatal injuries
Metabolic and toxic disorders
Head trauma
Tumors
Vascular disorders
Degenerative disorders
Infectious diseases

 Hypoxia,hyoglycemia,hypocalcemia
Flashing lights, fatigue, missed
meal,decreased physical
strength,alcohol ingestion, physical or
emotional stress, sleep and menstrual
cycle
Care in selection of LA
Conscious sedation N2O O2 &
benzodiazepins

Management of petitmal
seizure
Position with feet elevated
If seizure ceases reassure the patient
Allow patient to recover before
discharge
If seizure continues for more than 5
minutes
Assess ABC and perform BLS

Drug overdose reactions

Management of toxic reactions to
epinephrine
Transitory rarely lasting for more than a
minute
Stop treatment
Place patient in most comfortable position
Monitor vital signs
Consider administrating oxygen
Allow time for the patient to recover

Epinephrine
Avoided in patients with history of stroke or
heart disease
Uterine contraction in pregnant female
Drug interactions : cocaine, MAO inhibitor
Management : ABC, activate EMS,administer
oxygen mask 10-15 l/minute
Start IV saline
Administer anticonvulsant versed
(midazolam) 2 mg then 1 mg/min
Vital signs
Recovery and discharge patient

Thank you