Dr/Baleegh Abdulraoof Al-kadasi

Definition.
- Medical emergencies are unexpected events that
lead to bodily injuries or medical conditions/crises.
-It may pose an immediate threat to an individual’s life.
-It is best prevented!
Dentists !! should be familiar with the prevention,
diagnosis, and management of common emergencies.
The most common medical emergencies include :
8- seizures
1- Syncope 9- Adrenal crises
2- Postural hypotension 10- Stroke
3- Angina pectoris 11- Hyperventilation
4- Cardiac arrest 12- Obstruction of airway
5- Heart failure 13- Asthma
6-Hypoglycemia 14- Bleeding
7- Hyperglycemia 15- anaphylaxis
 Prevention
of emergencies

Most emergencies can be prevented by adequate preparation of the patient

and staff. The following are suggested guidelines :
1.Take case history .
2.A visual inspection will allow you to have an idea about the
patient’s general health status.
2- Remind patients to take their normal medications on the day of their
appointment.

3- Procedures should be scheduled around meal times for diabetics.

4- Repeatedly assessing the patient whilst undertaking treatment,

noting any changes in appearance or behavior.
5- All staff members should be trained in basic first aid
procedure and basic life support (CPR)
6- The emergency kit should be readily available and each staff
members should know where it is located.
 Managing of emergency
• For all medical emergencies a structured
approach to assessment and reassessment of
patient for accurate diagnosis is made .
 Managing of emergency
1. recognizing an emergency .
2. Shout for help
3. ABC assessment and vital signs :
• A. air way
• B. breathing
• C. circulation
 Vital signs
• Body Temperature : 36.8 -37.3°C
• (axillary is less 0.5 while rectal is more by 0.5°C)
• Pulse rate 60-90 / min .
• Blood pressure : Systolic 100-140 mmHg
Diastolic 60- 90 mmHg
• The blood pressure of children is usually lower than ranges considered
healthy for adults
• Respiratory rate 12-18
A: Airway
• Open airway
• Remove any dental material from patient mouth
• Use head tilt and chin left
• Suction if possible
B: Breathing
• Normal adult rate 12 -20 breaths per minute

• Child breathing rate 20-30 breath per minute

• Count respiratory rate (finger in front of nose opening)

• If not breathing give two breath via pocket mask

• Insert oral air way if apneic

C: Circulation
• Look to color of hand and finger (Are they blue ,pink .pale)

• Assess limb temperature by feeling the patient hand

• Count patient pulse rate (carotid pulse or ,radial pulse )

Weak pulse in patient with decreased conscious may suggest

hypotension (laying patient down and raising legs ).
Carotid and radial pulse
Emergency procedure
1- Stop dental procedure

2- Call for local assistance

3- Stay calm

4- Look to patient generally to see if they look unwell.

5- In an awake patient ask (how are you ) if the patient is unresponsive shake him
and ask (are you all right) if they respond normally they have clear air way, and
breathing ,and have brain perfusion .
Emergency procedure

6- If speak only with short sentences . They may have

breathing problems.

7- Assess the patient ABC and vital signs.

8- Check that emergency service are coming .

9- Do correct positioning and drug administration

Emergency kit
• Every dental office should have an
emergency kit.

• Place the kit prominent easy accessible

location .

• Check of kit content periodically.

Emergency kit
A- equipment :
• Oxygen cylinder with mask and cannules.
• Oral air way
• Pocket mask
• Blood pressure cuff and stethoscope.
• Automated external defibrillator.
• suction tips
 Emergency kit
B-drugs:
1. Epinephrine 1:1000 .o.5 - 1 ml injection. (anaphylaxis , asthma)
2. Aspirin 300mg PO (myocardial infaraction )
3. Diphenhydramine 50 mg IM ( allergy )
4. Nitroglycerin 0.4 mg SL (angina pectoris )
5. Oral glucose(tablet ,solution, gel) or give 5 g glucose powder in water.
(hypoglycemia)
6. Glucagon 1mg. IM (hypoglycemia)
7. Salbutamol aerosol (asthma )
 Emergency kit
Other drugs
-Midazolam10 mg . (epilepsy )
-Hydrocortisone sodium succinate 50mg /ml . ( Allergy , asthma)
-Propranolol 2.5 mg in 10 ml ampule. (hypertension )
-Atropine 5mg/ml in 1ml vial. ( bradycardia )
-Morphine 30 mg ( angina , myocardial infarcation )
-Naloxone 4mg /ml in 1ml ampule IV,IM,SC ( morphine antagonist )
-Flumazenil 1mg/ml vial. ( benzodiazepine antagonist )
 SYNCOPE
• Syncope (Fainting) is a temporary loss of Consciousness that mainly occur due to
(diminished cerebral blood flow)

• usually occur when person is exposed to a specific trigger (pain, scary, sight of
blood.. else)
• vagus nerve stimulation → vasodilation of blood vessels of vescera and
extrimities → diminished cerebral blood flow → syncope
Signs & Symptoms
■ Slow pulse rate
■ Low blood pressure
■ Pallor and sweating
■ Nausea and vomiting
■ Loss of consciousness.
Treatment
The main goal of our management is to allow the blood return to
the brain and keep the patient safe and prevention of farther
complications.
 Treatment
1-Lay the patient flat as soon as possible and raise the legs to improve
venous return.

2- Loosen any tight clothing, especially around the neck and give oxygen

3- If any patient becomes unresponsive, always check for ‘signs of life’

ABC and start CPR in the absence of signs of life or normal breathing
 Postural Hypotension
Definition:

- A disorder of the autonomic nervous system in which syncope

occurs when the patient assumes the upright position and
differs from vasodepressor syncope as not associated with
stress or fear.
 Predisposing Factors
1- Drugs: e.g. some antihypertensives , phenothiazines ,narcotics tricyclic
antidepressant and antiparkinson drugs.

2- Prolonged recumbency and convalescence.

3- Inadequate postural reflexes.

4- Pregnency.

5- Venous defects in the legs.

6- Addison's disease.

7- Fatigue, starvation, and physical exhaustion.

Prevention
1- Medical history: to detect presence of any of the predisposing factors.

2- Dental therapy considerations: patient should avoid too rapid rising from sitting
position.
Management
1- Patient is positioned supine with legs slightly elevated.

2- Airway is maintained.

3- Slowly reposition chair.

4- Discharge patient.
 HYPOGLYCAEMIA
What is it ?
■ Decrease Gloucose level in the blood stream.

■ Hypoglycaemia is dangerous because the brain becomes starved of glucose.

 Causes
• The most common cause of hypoglycemia is medications used to
treat Diabetes mellitus such as insulin ,and Sulfonylureas

• Other causes of hypoglycemia include kidney failure ,

certain tumor , liver disease , hypothyroidism , starvation , inborn
error of metabolism , severe infection , reactive hypoglycemia ,
and a number of drugs including alcohol
 Causes
• Serious illness

- hospitalized persons, especially in intensive care unit or those prevented

from eating

• Hormone deficiency

-Not enough cortisol, such as in Addison's disease not enough glucagon, or

not enough epinephrine can result in low blood sugar. This is a more
common cause in children.
Symptoms and signs
Mild symptoms
■ Shaking and trembling
■ Sweating
■ Headache
■ Unconsciousness.
■ Pallor
■ Heart palpaiton
Symptoms and signs
Severe symptoms :
■ Slurring of speech
■ Aggression and confusion
■ Fitting/seizures (uncommon )
■ Unconsciousness. (uncommon )
 Treatment
Early stages (where the patient is co-operative and conscious):

- give oral glucose (sugar), milk with added sugar, glucose tablets or gel . If necessary this
may be repeated in 10–15 minutes.

-Given a drink containing glucose and if possible some food high in carbohydrate.
 Treatment of hypoglycemia
In more severe cases (where the patient has impaired consciousness, is uncooperative or is
unable to swallow safely)
■ Glucagon should be given via the IM route (1 mg in adults and children > 8 years old or >25
kg, 0.5 mg if <8 years old or <25 kg).

■ Recheck blood glucose after 10 minutes to ensure that it has risen.

Hyperglycemia
Hyperglycemia( ketoacidosis))
• -Occurs when the body can't use insulin properly or when there is not enough
insulin available to move glucose into cell.

• -This causes the cell to use fats and proteins for energy, leaving behind waste
products which build up in the blood.

• Over time. From hours to days to sometimes weeks. The blood sugar level
continually increase.
Signs and symptoms
1- Hyperventilation
2- Acetone odor on breath
3- Warm , red, dry skin
4- Severe dehydration and polyuria
5- vomiting and tachypnea
6- Unconsciousness
Treatment
1- treatment of DKA with intravenous insulin or subcutaneous up to
80 U/h
2- monitor vital signs.
3- call 911
Anaphylaxis ( anaphylactic shock)
• Anaphylaxis is a potentially life-threatening, systemic allergic reaction
caused by the release of histamine and other vasoactive mediators
from mast cells.

Mechanism of action: type I reaction resulting

1- generalized vasodilatation

2- bronchospasm
 ANAPHYLAXIS
CAUSES:

1-pencicillins ,the most common cause but also other antimicrobial(

cephalosporin, sulphonamides , tetracyclines , vancomycin).

2- anesthetic solution

3-muscle relaxants

4-NSAIDs

5-opiates

6-others : vaccines , immunoglobulins , various food and insect bites .

Anaphylaxis ( anaphylactic shock)
Clinical features: (quickly reaction within 30 minutes)
Start as:

1- Paresthesia and edema of the face.

2-Coldness of hands and feet.

3- Wheeze due to bronchospasm.

In severe cases:
1- Rapid severe fall of blood pressure

2- Pallor and sweeting

3- Fast pulse

4- Loss of consciousness
ANAPHYLAXIS
Anaphylaxis ( anaphylactic shock)

Clinical features: (quickly reaction within 30 minutes)

Later:

1- The patient is pulseless

2- Cyanosis from inadequate oxygenation.

3- Death may occur within five minutes.

Emergency management of anaphylaxis
1- Prevent further contact with allergen

2- Ensure airway patency

3- Lay the patient flat with legs raised (to improve venous return from the body peripheral regions to
the heart and increase blood flow to the brain)

4- Administer intramuscular adrenaline (epinephrine)

- 0.5 ml (1/1000 conc.) i.m.

- Readminstrated after 5 minutes if there is no improvement with maximum dose of 1.5 ml.?
Cardiopulomanary resuscitation (CPR)

5- Oxygen and monitoring the vital signs (at least every 5 minutes).

(position, adrenaline and oxygen only steps in life threating phase of anaphylactic shock)
Emergency management of anaphylaxis
• Administer antihistamines
e.g. Chlorphenamine 10 mg IM., injection followed by 50mg of oral
diphenhydramine every 6 hours for 24 hours.
• Directly opposes effects of histamine released by activated mast
cells
• Administer corticosteroids
e.g. Hydrocortisone sodium succinate 200 mg IV every hours for 24
hours
• Prevents rebound symptoms in severely affected patients
 ADRENAL CRISIS
• Definition : is a potentially fatal condition associated
mainly with an acute deficiency of the glucocorticoid
cortisol and, to a lesser extent, the mineralocorticoid
aldosterone. it occurs commonly in people with long-
term adrenal insufficiency.

• --we should ask patient for the history of take

corticosteroids.
 Etiology
Adrenal insufficiency :
1. congenital adrenal insufficiency
2.Primary : Addison disease
3.secondary : - exogenous steroid
- surgical excision of gland
- pituitary insufficiency
Certain condition :
1.Stress, trauma
2.Infection
3.Surgery
 Clinical feature
1. Severe hypotension
2. Weakness
3. Dehydration
4. GI symptoms
5. Even death
 DENTAL MANAGEMENT
Dental treatment Last steroid dose ? Last steroid doses ? Steroid doses ? is
was taken more was taken less than 1 taken currently
than 1 month month ago
Conservative dentistry or No • Give hydrocortisone 200 orally or iv pre operative
minor oral surgery under cover - Then continue
LA : single extraction required normal
medication

Intermediate surgery • Consider cover if large • Give hydrocortisone 200mg iv pre.op and 6hourly for 24
(multiple extraction or doses of steroid were hours
surgery under GA) given -then continue
normal
• Test adrenal function medication
Major surgery – trauma by ACTH stimulation • Give hydrocortisone 200mg iv pre.op and im 6 hourly for
(maxillofacial surgery) test 72 hours
-then continue
normal
medication
Angina pectoris
• Angina pectoris is narrowing of coronary artery (atherosclerosis ) and unable of
supply of heart muscle of adequate amount of oxygenated blood.

• Lead for sever chest pain for short duration.

 Types of angina
• Stable angina

'effort angina’ this refers to the classic type of angina related to myocardial ischemia. A
typical presentation of stable angina is that of chest discomfort and associated
symptoms precipitated by some activity (running, walking, etc.)

• Unstable angina

it occurs at rest (or with minimal exertion), usually lasting more than 10 minutes

more severe, prolonged, or frequent than before).

 Sings and symptoms
1-Central, substernal chest discomfort ,pain May radiate
into shoulders, arms, neck, jaw, or epigastric region

2-Dull, heavy, pressure sensation of short duration (< 5

min )

3-may be accompanied by breathlessness, sweating, and

nausea in some case.

Chest pain lasting only a few seconds is normally not

angina
Treatment
1.Keep patient in comfortable position
2.Administer oxygen
3.Administer nitroglycerin 0.5 mg SubLingual
every five minutes
4.Monitor vital signs

• Call 911 if pain not relieved in five minutes

 Myocardial infarction
Definition:

refers to the ischemic necrosis of an

area of the heart, which caused by
complete blocking of some branches of
the coronary arteries.
 Symptoms and signs of myocardial infarction

1- Progressive onset of severe, crushing pain.

2- Skin becomes pale and clammy.

3- Nausea and vomiting (common).

4- Pulse may be weak and blood pressure may fall.

5- Shortness of breath.
 Management of myocardial infarction in dental clinic

1- Call to emergencies immediately for an ambulance.

2- Allow the patient to rest in the position that feels most

comfortable

3- Give aspirin in a single dose of 300 mg orally.

4- High-flow oxygen may be administered (15 litres per minute).

5- If the patient becomes unresponsive always check for ‘signs

of life’ (breathing and circulation) and start CPR in the absence
of signs of life.
HEART FAILURE
 HEART FAILURE
• Result when one of ventricles is unable to
completely pump all the blood filling the
ventricles

• It is not disease, it is a complication of some

diseases as ischemic heart disease,
hypertension and thyrotoxicosis .
 Main causes of heart failure
1-Ischaemic heart disease

2-Hypertension

3-Chronic obstructive pulmonary disease

4-Pulmonary embolism

5-Cardiomyopathies

6-Arrhythmias
signs and symptoms
1-cyanosis of face ,lip.
2-pitting edema of extremeties.
3-pulmonary edma
4-dyspnea on exertion
5-orthopnea .
6- Fatigue and weakness
Treatment

1-Terminate dental oppointment .

2-Remove dental material and instruments from the patient mouth .

3-Put the patient in upright position.

4-Ask for emergency medical services .

 Cardiac arrest
is sudden stop in effective blood flow due to the
failure of the heart to contract effectively . It occurs instantly or shortly after
symptoms appear.
 What causes a cardiac arrest?

• Heart and circulatory disease (eg. a heart attack)

• extreme blood or fluid loss
• extreme body temperature (both too high or too low)
• blood potassium levels that are too high)
• lack of oxygen
• Pulmonary embolism
 Signs & Symptoms
- Chest pain.
- Loss of consciousness .
- Abnormal or absent breathing.
-nausea.
- If not treat within minutes death usually occurs.
 Managment of CR
1-inject epinephrene inside heart
2-CPR Where a defibrillator is available, carry out early defibrillation
Or use Chest compressions.
4- Rescue breaths.
5- Continue CPR.
Bleeding
• , also known as hemorrhage , Is the blood escaping from circulatory
system
• Type of bleeding :
1- internal bleeding
2- external bleeding
BLEEDING
• Bleeding in dental clinic:
1- bleeding after surgery
2- trauma
3- systemic disease
Management of the bleeding patient
● Assess airway, breathing, circulation.

● Reassure the patient.

Post-extraction bleeding often worries the patient

excessively because a little blood dissolved in saliva

gives the impression of a major bleed

● Gently clean the mouth

● Locate the source of the bleeding

Management of the bleeding patient
Suture the socket under local analgesia

● Enquire into the patient’s history, especially family

history of abnormal Bleeding

● use of thrombine or tranexamic acid mouthwash

5%, which may help to stabilize the clot in the interim

● I f the bleeding is uncontrollable, call an ambulance.

ASTHMA
ASTHMA

• is chronic inflammatory disease of

airway of lungs

• hypersensitivity reaction→
bronchospasm .

• caused by combination of gentic and

environmental factors
CAUSES
1- Anxiety.
2- infection.
3- exposure to an allergen
4- chemical irritant
Symptoms and signs

1-Shortness of breath
2-wheezing; coughing
3- tightness in chest
4- tachycardia
 Management
1. Sit patient upright or in a comfortable position

2. Administer oxygen

3. Administer bronchodilator(Albuterol or salbutamol )

4. If bronchodilator is ineffective , administer epinephrine

5. Call for emergency medical services with transportation for

advanced care if indicated
Hyperventilation
• Hyperventilation or over-breathing is the state of breathing
faster and/or deeper than necessary.
• Results from a psychological state.
• Rapid reduction of CO2 (imbalance between CO2 and O2 )
• More than 20 (respiratory rate)
 Causes of hyperventilation include:
1-anxiety .
2-pain
3-cardiovascular disease
4-nervous system disease
5-acidosis (either metabolic or drug-associated)
6-various lung diseases
 clinical features
1-anxiety
2-weakness
3-dizziness
4- over breathing
5- headache
6-disturbed consciousness( sever cases)
Management of hyperventilating patients
● Assess airway, breathing and circulation

● Reassure the patient

● Encourage the patient to decrease the respiratory rate slowly

breathing In And Out in paper bag maybe help

● administrate Alprazolam

● If there is obvious sympathetic over activity, as shown particularly

by tachycardia or arrhythmias, a beta-blocker may be necessary

● Defer dental treatment until medical assessment has taken place

Seizure
• Defination
is the misfiring of the neurons inside the human brain and result in
abnormal movements or behavior due to unusual electrical activity .

• Seizure is considered to be a symptom of epilepsy

Classification of seizure
A - Provoked seizures (Non-epileptic seizures )

are single seizures that may occur as the result of:

- Fever
- Head injury
- Electrolyte imbalance , low blood sodium
- Brain tumor or lesion
- Infection, such as meningitis or encephalitis
- Withdrawal from alcohol or drugs
B- epileptic seizures :
Seizure disorder is a general term that it is often used in
place of the term ''epilepsy.''
Common triggers for seizure include:

1.Alcohol, drugs, and caffeine

2.Nicotine
3.Poor sleep
4. high level of stress.
Manifestations of Seizure
1.falling down and shaking violently or having stiff, jerky movements

2.Have muscle spasms

3.Make involuntary movements

4.Have disruptions to his or her speech, movement, vision, or senses

How to manage seizure attack in your dental clinic
How to manage seizure attack in your dental clinic
1- ABC and vital signs assessment
2-Remove glasses and piercing, if present. Also remove potentially harmful
objects out of the way of the person.
3-Turn the person on one side and place him mouth to ground.
4-Never leave the person, stay by him, until the seizure has passed. Then
help him reorient.
5- if seizure more than 5 minute (prolonged seizure) give the patient
diazepam
 STROKE

`A stroke is partial loss of fuction in the brain due to disruption in the blood
supply to the brain..
 TYPES OF STROK
Ischaemic strokes are caused by blockages (usually blood clots),or
atherosclerosis in one of the arteries supplying the brain.

Haemorrhagic strokes are caused by one of the blood vessels supplying

the brain bursting and causing a bleed(hypertension)
 Predisposing factor
-Smoking
-increase cholesterol in the blood
-Hypertension
-diabetes
-obesity .
 Clinical manifestation
1- Physical problems in one side of the body (numbness, weakness),drooping in one
side of the face,

2-speech problems (slurred speech, muddled words),

3-visual problems (blurred vision, loss of vision) .

4-others (vomiting ,headache ,dizziness )

• In more serious cases, the person might lose consciousness.

 Management of stroke
1-clear the airway and check breathing
2-Check pulse and capillary refill
3-Reassure the patient
4-give high-flow oxygen
5-Call an ambulance
Obstruction of Airway
Emergency
signs & features :
snoring
- arises when the pharynx is partially occluded by the tongue or palate

stridor
caused by obstruction at or above laryngeal level.

Expiratory wheeze
caused by obstruction of lower airways.

Gurgling
suggests there is liquid or semi-solid foreign material in the
upper airway
signs & features :
central cyanisis
ot eud( noticurtsbo yawria fo ngis etal a si )eugnot dna spil eulb( .
yrotaripser dna caidrac morf gntiluser doolb lairetra lartnec fo notiarutased
)sredrosid

paradoxical’ chest and abdominal movements

(‘see-saw’ respirations) and the use of the accessory muscles of
respiration, e.g. neck muscles..
■ Causes of respiratory obstruction

mechanical
foreign body & solid object eg. ( crown , dental material or instruments )

anatomical
tongue -most common
*foreign body resbiratory obstruction

Prevention
Prevention of inhalation of foreign bodies, including teeth, crowns, filling
materials or endodontic instruments, is far better than the event occurring.

■Use a rubber dam

#mangement
* ◆ In most cases, only simple methods of airway
clearance are needed

1- Airway opening manoeuvres . Jaw thrust.

- help to improve the patency of the airway ,allowing

passage of air into and out of the lungs .

- Head tilt/chin lift or jaw thrust.

- Remove visible foreign bodies, debris or blood from the airway (use suction or
forceps as necessary).
•Airway opening manoeuvres

- Consider simple airway adjuncts, e.g. oropharyngeal airway

* Give oxygen initially at a high inspired
concentration:

◆ Use a mask with an oxygen reservoir

- Ensure that the oxygen flow is sufficient (15 litres per minute) to prevent collapse of the
reservoir during inspiration
 2-Tracheal intubation
is the placement of a flexible plastic tube into the trachea (windpipe( to maintain
an open airway
1-Orotracheal The most widely used route is orotracheal, in which an
endotracheal tube is passed through the mouth and vocal apparatus into the
trachea.

2-Nasotracheal
 3-Tracheotomy

is a surgical procedure which consists of making an incision on the anterior aspect of

the neck and opening a direct airway through an incision in the trachea