Dental Office Emergencies
Be prepared
Be alert
Anticipate
By
Dr Saikat Saha
Successful Prevention
Updated
medical & health history
Operator & patient rapport
Minimal stress level
Observation
Vital signs - baseline
By
Dr Saikat Saha
Patient Assessment
Four
R
step treatment approach
- recognition of disease
A -
assessment of the risk
- management for safety
- emergency care
By
Dr Saikat Saha
Dental Hygienists Role
RDH
often the first to
recognize a potential
medical emergency
Observe and monitor
throughout care
patients changes in
expression, skin tone,
muscle tonus,
respiration, verbal
expressions
By
Dr Saikat Saha
Dental Hygienist Role
Course
in First Aid
desirable
Course in CPR
required
Classify responses
and know when
emergency situation
seems imminent
Prompt,appropriate
reactions to signs of
distress
Ability to provide care
until help is secured
Provide complete
description of distress
signs to DDS and
EMT
By
Dr Saikat Saha
Being Prepared to React
Emergency
phone
numbers
Rehearsal of
emergency scenario
Procedures for
alerting other staff
members
Write
out specific
protocols for action in
the event of medical
emergency
Specific assignments
made to ensure all
designated
procedures
completed
By
Dr Saikat Saha
Generic Functions of Emergency
Response Tasks
Evaluate
vital signs
Diagnose nature of
emergency
Decide on appropriate
treatment
Instruct others what to
do
Phone for help
Prepare
for treatment
administration
Administer treatment
Monitor vital signs
Reassure patient
Record events that
occur
Ensure privacy/and or
manage other patients
By
Dr Saikat Saha
Medical Emergencies
Predisposition
to emergency
Patient
with HBP, Cardiac insufficiency, asthma,
angina,diabetes
High
anxiety levels
Combination
of both may trigger physical response
that could be classified as emergency
By
Dr Saikat Saha
Medical Emergency Prevention
Practitioner
must be able to
Recognize
Modify
patient anxiety
dental therapy
Prevent
an emergency
By
Dr Saikat Saha
Emergency Situation
Most
responses to emergencies can be
managed
using basic life support (without
use
of drugs) until advanced life support
can
arrive.
By
Dr Saikat Saha
Intro: Adrenal Crisis
Adrenal
gland consists of two distinct
regions .
Adrenal
cortex produces endogenous steroids.
Medulla produces and secretes epinephrine
and norepinephrine.
Hypofunction of adrenal cortex results in
decreased cortisol production. Cortisol
necessary to help body react to stressful
situations.
By
Dr Saikat Saha
Intro: Adrenal Crisis
Individuals
with decreased cortisol
production cannot respond to stress and risk
cardiovascular collapse and possible death.
Patients may be taking supplement.
(Addisons disease)
May need to increase level of exogenous
steroids before undergoing stressful
procedures
By
Dr Saikat Saha
Signs & Symptoms: Adrenal Crisis
Shocklike
symptoms(cardiovascular
collapse)
Hypotension
Bradycardia
Fever
Respiratory
depression
Hypercalcemia
Lethargy
By
Dr Saikat Saha
Treatment: Adrenal Crisis
Terminate
treatment
Monitor and record vital signs
Place patient in Trendelenburgs position
Access and support airway, breathing,
circulation- BLS
Activate emergency protocol
Provide supplemental oxygen
Administer saline, hydrocortisone
By
Dr Saikat Saha
Intro: Airway Obstruction
Unlikely
to occur while being treated
Upper airway obstruction usually
reversible
Most common is unconsciousness tongue and epiglottis occluding airway
Can cause loss of consciousness and
cardiac arrest
By
Dr Saikat Saha
Intro: Airway Obstruction
Diagnose
partial versus complete is
critical and must be done rapidly to
prevent complications of anoxia
Partial:
person is making coughing or other
noises
Complete: no noises are made although
patient is attempting to cough or talk,
showing signal for choking
By
Dr Saikat Saha
Signs & Symptoms:Airway Obstruction
Flushed
face
Extreme
anxiety
Choking
Gagging
Cyanosis
Violent
efforts
inspiratory
Cardiovascular
collapse
By
Dr Saikat Saha
Treatment: Airway Obstruction
Position
head
Remove foreign object
sweeping
motion of fingers
Magil or straight forceps
Suction
Perform
abdominal thrusts/Heimlich
manuever
Repeat as needed, cricothyrotomy
By
Dr Saikat Saha
Intro: Anaphylaxis/Allergy
Allergy-hypersensitive
state results from
exposure to allergen.
Range in clinical manifestation from
immediate-life threatening condition seen
within seconds or delayed type reaction
which may not manifest until hours or days
after exposure.
By
Dr Saikat Saha
Intro: Anaphylaxis/Allergy
Immediate
or anaphylactic reaction that
occur in the dental office pose greatest
risk to patient and are of greatest concern
to dental staff.
Usually result from drug administration or
reaction to an allergen in impression
material or other materials used in oral
cavity.
By
Dr Saikat Saha
Intro: Anaphylaxis/Allergy
Generalized
most life threatening and
dramatic allergic reaction.
Death can occur in minutes if not treated
appropriately.
Reactions affect skin,smooth
muscle,respiratory and cardiovascular
system
By
Dr Saikat Saha
Intro: Anaphylaxis/Allergy
Anaphylactic
shock occurs when
consciousness lost as result of hypotension
from an anaphylactic reaction.
Symptoms begin with skin,followed by
eyes,nose,and gastrointestinal system,then
respiratory system, finally cardiovascular
symptoms develop
Prompt therapy can stop reaction
By
Dr Saikat Saha
Signs & Symptoms:
Anaphylaxis/Allergy
Urticaria-
Laryngeal
edema
itching,flushing,hives
Weak
pulse-syncope
Rash
Loss
Rhinitis
Bronchospasm
of
consciousness
Cardiac
By
Dr Saikat Saha
arrest
Treatment: Anaphylaxis/Allergy
Acute
Reaction:
Basic
Life Support
Epinephrine, injection IM
Oxygen
Diphenhydramine, injection IM
Corticosteroid
CPR
Airway management - intubation,
cricothyrotomy
By
Dr Saikat Saha
Signs & Symptoms:
Anaphylactic Shock
Anaphylactic
reaction: immediate allergic
response
For
any allergic reaction to occur patient had
to have previous exposure to antigen-called
sensitizing dose
Subsequent exposure to antigne termed
challenging dose
By
Dr Saikat Saha
Intro: Anesthesia Reactions
Reaction
can be varied in extent and severity
Most are result of either local anesthetic
agent itself or the vasoconstrictor within
formulation
Toxicity can occur especially from rapid
intravascular injection
Reaction can occur 30-60 seconds to 1 hour
after injection
By
Dr Saikat Saha
Intro: Anesthesia Reactions
Local
anesthetic
dosing should be
calculated on:
patients physical
condition
body weight
By
Dr Saikat Saha
Signs & Symptoms: Local
Anesthesia Reactions
Light
headedness
Slurred
speech
Diasphoresis
Blurred vision Anxiety
Nystagmus
Change
Tinnitus
mental status
Confusion
Headache
Seizures
Disorientation Tremors
Tachypnea
Drowsiness
Nausea/
Vomiting
By
Dr Saikat Saha
Bradycardia
Signs & Symptoms:
Vasoconstrictor Toxicity
Anxiety
Tachypnea
Tachycardia/
Chest
pain
palpitations
Dysrhythmias
Restlessness
Cardiac
Headache
By
Dr Saikat Saha
arrest
Treatment:Local Anesthesia
Toxicity
Initially, begin
basic cardiac life support
Assess and support
airway,breathing,circulation
Supportive treatment may be indicated
Airway opened, oxygen given
Severe reactions, patient transported to
hospital emergency room as soon as
possible
By
Dr Saikat Saha
Intro: Angina Pectoris
Chest
pain caused by temporary myocardial
ischemia without damage to heart muscle.
Due to narrowed coronary arteries inability to
supply myocardium with sufficient blood to
meet hearts demand for oxygen during times
of stress.
Can be caused by atherosclerosis,coronary
artery vasospasm, or combination of both.
By
Dr Saikat Saha
Intro: Angina Pectoris
Detailed
medical history important to
prevent these occurrences.
Try
to quantify the extent and pattern of
the disease before beginning treatment.
In
other words, know what types of
activities have caused symptoms in past.
By
Dr Saikat Saha
Signs & Symptoms:
Angina Pectoris
Chest
pain brought on by myocardial
stress - left center or center chest
Chest fullness
Burning
Tightness
Pain radiating to neck,left
arm,jaw,back,shoulder and epigastrium
By
Dr Saikat Saha
Signs & Symptoms:
Angina Pectoris
Weakness
Dyspnea
Nausea
Diaphoresis
Pain
can last up to 20 minutes; prolonged
discomfort should be evaluated at
emergency medical facility
By
Dr Saikat Saha
Treatment: Angina Pectoris
Avoid
situations needing increased
oxygen demands
Stop procedure and allow patient to rest
Monitor vital signs repeatedly
Place patient in semireclined position
Provide supplemental oxygen
By
Dr Saikat Saha
Treatment: Angina Pectoris
Administer
sublingual
nitroglycerin(0.4mg)
every five minutes for
three doses
If not relieved, patient
may be having
myocardial infarction
and transport to
emergency medical
facility
By
Dr Saikat Saha
Intro: Asthma
Group
of illnesses producing a reversible
hyperreactivity of large and small airways
Individuals may react to many stimuli
Incidence is rising in general population
Triggering factors include pollen,
stress,cold,upper respiratory tract
infections, exercise, animal fur, nonsteroidal
antiinflammatory medications
By
Dr Saikat Saha
Signs & Symptoms: Asthma
Wheezing
Shortness
of breath
Cough
Sputum
production
Use of accessory muscles for breathing
Tachycardia
By
Dr Saikat Saha
Treatment: Asthma
Objective
is to improve ventilation by reducing
or eliminating brochospasm
Patient removed from irritants
Inhalants used: Albuterol-Ventolin,Proventil or
Terbutaline
Monitor vital signs
Possible oxygen supplement
Assess need for emergency medical treatment
By
Dr Saikat Saha
Intro: Cardiac Dysrhythmias
Commonly
known as heart palpitations
Often result of anxiety over dental
procedures
Can be result of epinephrine given in local
anesthetic or of underlying cardiac
condition
Use simple reassurance to patient
More severe may need more intervention
By
Dr Saikat Saha
Signs & Symptoms:
Cardiac Dysrhythmias
Racing
heart (tachycardia)
Irregular heart beat
Apprehension
Chest discomfort
Light-headedness
Chest pain
By
Dr Saikat Saha
Treatment: Cardiac Dysrhythmias
Monitor
vital signs
Place patient in reclined position
Administer supplemental oxygen
Activate EMS
By
Dr Saikat Saha
Intro: Cerebrovascular Accident/Stroke
Process
that interferes with blood flow to
the brain
Prolonged ischemic event causes
infarction of part of brain. Can result in
neurologic deficit.
Three major causes of stroke: arterial
thrombosis, embolism, hemorrhage of the
vasculature
By
Dr Saikat Saha
Signs & Symptoms: Cerebrovascular
Accident/Stroke
Headache
Extremity
weakness
Confusion
Vertigo
Facial
weakness
Nausea/vomiting
Hypertension
Alteration
in
consciousness,vision
& speech
Change
status
By
Dr Saikat Saha
in mental
Treatment:
Cerebrovascular Accident/Stroke
Assess
and monitor vital signs
Initiate basic cardiac life support as
needed
Administer oxygen if patient goes
unconscious or has trouble breathing
Place patient in supine position with head
slightly elevated
Activate EMS
By
Dr Saikat Saha
Intro: Congestive Heart Failure
Failure
of cardiac ventricles to pump blood
efficiently to the body and lungs.
Result is pulmonary edema and peripheral
edema, overfilling venous system.
Pulmonary edema can be result of lung
disease or left ventricular failure.
By
Dr Saikat Saha
Intro: Congestive Heart Failure
Causes of acute onset:
new
arrhythmias
new
myocardial infarction
acute
volume overload
stress
By
Dr Saikat Saha
Signs & Symptoms:
Congestive Heart Failure
Shortness
of breath
Exertional dyspnea
Fatigue
Orthopnea(2-3 pillows
to sleep)
Cough
Rales (crackle) at
lung base
Edema-right
side
failure
Plural effusion (fluid in
the lungs)
Pink frothy sputum
Jugular venous
distention
By
Dr Saikat Saha
Treatment:
Congestive Heart Failure
Correct
underlying cause
Stress-
Infection - Environmental
conditions(heat)
Administer
supplemental oxygen
Activate emergency response
Monitor vital signs
Discontinue procedure
Have patient rest in semireclined position
By
Dr Saikat Saha
Intro: Drug Related Emergencies
Therapeutic
agents can precipitate physiologic
crisis
Present as allergic or toxic reactions
Drug abuse most commonly found are alcohol
or cocaine related
Act on central nervous system
Be aware of signs of drug abuse and drug
interactions
Explicit directions for patients drug use
By
Dr Saikat Saha
Intro: Drug Related Emergencies
Therapeutic
agents can precipitate physiologic
crisis
Present as allergic or toxic reactions
Drug abuse most commonly found are alcohol
or cocaine related
Act on central nervous system
Be aware of signs of drug abuse and drug
interactions
Explicit directions for patients drug use
By
Dr Saikat Saha
Signs & Symptoms: Drug Related
Emergencies
Actions
on CNS
Stimulation: Headache,
Nausea,Vomiting,
Vertigo, Twitching small
muscles,
Hallucinations,
Increased RR,Elevated
body temp,Agitated,
Restless,Excitation
Advanced
Stimulation:
Seizures.Decreased
response to
stimuli,Incontinence,
Tachycardia,Hyperten
sion, Weak rapid
pulse, Rapid irregular
breathing
By
Dr Saikat Saha
Signs & Symptoms:
Drug Related Emergencies
Depression:
Premorbid State
coma
pupils
fixed and dilated
flaccid paralysis
cardiac arrest
respiratory arrest
cyanosis
lethargy, stupor
By
Dr Saikat Saha
Treatment:
Drug Related Emergencies
Hypotension
with evidence of shock in non
responsive individuals is indication for
parenteral fluid therapy.
Activate emergency procedures protocol.
Basic life support
CPR
By
Dr Saikat Saha
Intro: Hyperglycemia
Increased
blood sugar
One
of two life threatening complications
of diabetes
Slow
to develop but if not treated can
result in diabetic coma and death
By
Dr Saikat Saha
Signs & Symptoms: Hyperglycemia
Deep,labored
Thirst
respirations
Lassitude
Sweet
fruity breath
Headache
Dry. Warm
skin
Rapid,weak
pulse
By
Dr Saikat Saha
Treatment: Hyperglycemia
Terminate
procedure
Administer glucose
Oral-
paste or drink(must be conscious)
IV
Perform
basic life support
Activate emergency response protocol
By
Dr Saikat Saha
Intro: Hypertension
Unlikely
to be seen but may manifest as
underlying cause of another crisis
Absolutely essential to control increased
blood pressure in response to any other
situation
Must decide if patient needs emergent or
referral care-depends on history or any
symptoms present
By
Dr Saikat Saha
Signs & Symptoms: Hypertension
Headache
Seizure
Vomiting
Shock
Change
Stroke
in mental
status
Blood
Visual
disturbance
Pressure
Readings - WNL
By
Dr Saikat Saha
Treatment: Hypertension
Discussed
elsewhere
to control blood
pressure
Must refer for care in
hospital by physicians
Focus on preventionmake sure medication
taken, anesthetic
w/out epinephrine
By
Dr Saikat Saha
Intro: Hyperventilation
Imbalance
in ratio of blood oxygen and
blood carbon dioxide levels
Produced by either rapid or excessively
deep respirations
Common occurrence in dental office as it
is result of anxiety or emotional stress
Recognition and management of patient
anxiety can prevent this problem
By
Dr Saikat Saha
Signs & Symptoms and Treatment:
Hyperventilation
Signs
& Symptoms:
Dizziness
Light-headedness
Numb fingers
Heart dysrhythmias
Abdominal cramps
Muscle cramps
Treatment:
Terminate
dental
treatment
Reassure the patient
Try to institute regular
respirations
Rebreath exhalations
to reverse alkalosis
(breath into hands/bag)
By
Dr Saikat Saha
Intro: Hypoglycemia
Condition
of acutely decreased blood
sugar
Life threatening- more critical than
hyperglycemia in emergency situation
Must be treated rapidly
Administration of glucose is indicated - will
not significantly affect patient
By
Dr Saikat Saha
Signs & Symptoms and Treatment:
Hypoglycemia
Signs
& Symptoms:
Hunger
Terminate
Nausea
Cool,
Treatment:
moist skin
Shallow respirations
Irritation
Confusion
Bizarre behavior
procedure
Administer glucose
Oral-paste
or drink
IV
Perform
basic life
support
Activate EMS
By
Dr Saikat Saha
Intro, Signs & Symptoms,
Treatment: Nose Bleed
Profuse
or uncontrolled bleeding: Apply
compression over bleeding area. Digital
pressure on pressure point of supplying
vessel.
Nosebleed:
Request
patient to pinch nostrils between thumb
and index finger for 5 minutes
Apply cold compress to back of neck or over nose
Upright position
By
Dr Saikat Saha
Intro: Intraoral Lacerations
Rare
but posssible
High speed handpieces, overzealous
subgingival scaling
Signs & Symptoms: Intraoral Lacerations
Bleeding-Pulsation,bright
red-arterial;
Oozing,dark,red-venous
Pain at trauma site or over area of swelling
Swelling,slowly or rapidly, ecchymosis
By
Dr Saikat Saha
Treatment: Intraoral Lacerations
Discontinue
treatment
Remove foreign bodies from mouth
Pressure applied to site with sterile gauze
Wound flushed and irrigated with saline
Follow emergency office protocol to inform
dentist of situation
May be cared for in office or referred to
oral surgeon
By
Dr Saikat Saha
Intro: Myocardial Infarction
Occurs
when myocardial oxygen demand
exceeds available oxygen supplied by
blood for an extended period.
Most myocardial infarctions result of
atherosclerotic coronary artery disease
Plaques develop and occlude coronal
arteries, decrease blood flow to
myocardium, cause irreversible damage
By
Dr Saikat Saha
Signs & Symptoms:
Myocardial Infarction
Chest
pain
Crushing
Radiating
to
neck,jaw,arm,back
Substernal
Hypertension
or
hypotension
Indigestion
Diaphoresis(sweating)
Shortness
of breath
Tachycardia or
bradycardia
Dysrhythmias
Loss of or alteration in
consciousness
By
Dr Saikat Saha
Treatment: Myocardial Infarction
Discontinue
dental treatment
Place patient in semireclined position
Administer supplemental oxygen
Continually monitor and record vital signs
Administer sublingual nitroglycerin 0.4mg
every 5 minute for 3 doses
If no improvement,activate EMS
By
Dr Saikat Saha
Intro: Ocular Injuries
Rare
but these type of injuries do occur
Need same prompt attention even though
not life threatening
Most ocular injuries affect trauma to
cornea or the globe itself
Want to minimize loss of visual acuity
Refer patient opthalmologist for definitive
treatment
By
Dr Saikat Saha
Signs & Symptoms:
Ocular Injuries
Chemical
Burns:
serious,alkali burns
are true emergncies
Mild
to severe pain
Blurred vision
Excessive tearing
Treatment:
Immediate copious
irrigation with tap water
Alkali and /or
acid burns require 1520 minutes of irrigation
before transportation
to opthalmologist for
immediate consult and
evaluation
By
Dr Saikat Saha
Treatment: Ocular Injuries
Foreign
object in eye: Caution patient not
to rub eye
Blink
repeatedly to stimulate tear flow.
Locate object by lifting and rolling back
eyelids.
Remove with tissue if possible or use eye
wash station.
Always have patient wear protective eyewear.
By
Dr Saikat Saha
Intro: Seizures
Sudden
and unexpected central
paroxysmal neuronal depolarization of
nerve cells that result in uncontrolled
muscular movement.
Two types:
Focal-
limited
Generalized- loss of consciousness
By
Dr Saikat Saha
Intro: Seizures
Caused
by:
head
injuries
infections
neoplasms
cerebrovascular disease
systemic conditions idiopathic
By
Dr Saikat Saha
Signs & Symptoms: Seizures
Feeling
of aura-visual,auditory or olfactory
sensory disturbance
Minor personality changes
Depression
Anxiety
Headache
Loss of consciousness, muscle rigidity
Tonic/Clonic movements
Treatment: Seizures
Place
patient in reclined or supine position
Protect patient from injury during seizure
Protect head from injury during seizure
Administer supplemental oxygen prn
Suction mouth secretions-turn head to side
if vomiting occurs-clear airway
Monitor vital signs
Initiate further support if needed
Treatment: Seizures
Do
not allow patients
to drive themselves
home. Arrange for
transportation home
by family member or
other service.
Intro: Shock
Condition
in which circulatory system
inadequately perfuses body tissues
resulting in cellular hypoxia
Hypovolemic shock: due to sudden and
acute loss of blood-secondary to trauma
Septic shock: vasodilatory action of
endotoxins produced by virulent systemic
bacteremia
Intro: Shock
Cardiogenic
shock: failure of heart to
pump a sufficient amount of blood to
maintain perfusion pressure
Neurogenic
shock: result of spinal cord
trauma causing loss of sympathetic
stimulation. Causes vasodilation.
Signs & Symptoms: Shock
Hypotension/postural
hypotension
Tachycardia
Cool
skin
Pale skin color
Anxiety
Change in mental status
Decrease capillary refill
Treatment: Shock
Goal
to maintain
perfusion pressure
and maintain
oxygenation to vital
organs and tissues
Monitor vital signs
Place in
Trendelenburg
position
Keep
quiet and warm
Activate EMS
Provide supplemental
oxygen
Monitor skin signs
and capillary
perfusion
Signs & Symptoms: Broken and
Lodged Instrument Tip
Dont
use incorrectly sharpened
instruments which are extremely thin
Dont force instruments out of contact area
To loosen: relax the face of the instrument
toward the tooth (close blade),Attempt to
back blade out of area
Instruct patient not to swallow,check floor
of mouth and in gingival tissue, x-ray prn
Signs & Symptoms: Emotional
Problems
Mental
condition can affect physical
condition: Hyperventilation,
lightheadedness,giddiness,anxiety,
confusion,dizziness,overbreathing,feelings
of suffocation,heart pounds, tingling or
numbness in extremities
Patient position should be upright;loosen
tight collar,reassure patient,breath into bag
Intro: Syncope
Vasodepressor
syncope,fainting occurs
during stressful situations
Usually benign, unless left untreated,fatal
Caused by transitory and sudden loss of
consciousness after cerebral ischemia
Place in supine position,restore blood flow
Intro: Syncope
Predisposing
factors:
fright,
pain
emotional
stress
anxiety
hunger
sudden
postural changes
exhaustion
Signs & Symptoms: Syncope
Early:
Loss
Late:
of color, pallor
Perspiration
Nausea
Increased heart rate
Feeling of warmth
Yawning
Dilated
pupils
Cold extremities
Hypotension
Dizziness
Loss of consciousness
By
Dr Saikat Saha
Treatment: Syncope
Position
patient-supine, head lower than
feet if possible
Maintain open airway
Administer oxygen
Administer ammonia inhalant
Monitor vital signs
Procedural Overview
Respond
in logical,
rehearsed pattern of
behavior
For each possible
situation clinician
should be prepared to
respond in
predetermined
fashion
Move
instruments or
other potentially
harmful equipment
Reposition chair
Go for help calmly
Let patient sit quietly
Locate Emergency
first Aid Kit
By
Dr Saikat Saha
Procedural Overview
Preparing
a syringe
for an intramuscular
injection (IM);
intravenous injection
(IV) or subcutaneous
injection.
Performing CPR
Directing
emergency
squad to right location
Prepare dental team
to respond by role
assignment according
to skill level and
abilities to react
appropriately
By
Dr Saikat Saha
Importance of Dental Hygienists
Role
Prompt,
appropriate
reaction may
avert
an emergency
save
a life
By
Dr Saikat Saha
References:
Braun,
Robert J. and Cutilli, Manuel of
Emergency Medical Treatment for the
Dental Team.1999.Media:Williams &
Wilkins.
Wilkins,Esther, Clinical Practice of the
Dental Hygienist,1994. Malvern:Williams
and Wilkins.
Woodall,Irene. Comprehensive Dental
Hygiene Care.1993.St.Louis:Mosby.
