Microsoft word - medical emergencies journal --venkateswarulu sir.

MEDICAL EMERGENCIES IN PEDODONTIC PRACTICE *Venkateswarlu. M
** Vanaja, K.K.E.
* Professor and Head,
Dept of Oral Medicine and Radiology, Kamineni Institute of Dental Sciences, Narketpally, Nalgonda District, A.P.
** Post Graduate Student in Hospital Administration Annamalai University, Tamilnadu, India.
ABSTRACT:
Medical emergencies occur on pedodontic practice. The dentist should familiar with this emergencies. A proper
training is necessary for the Dentist as well as staff to deal with this emergencies. This article reviews some of
the common medical emergencies and conditions that may pose threat to the patient during dental treatment.
This review also provides some guidelines to their management if they were to happen in practice
Key words: medical emergencies ,, pedodontic patient
INTRODUCTION
with unstable or severe medical conditions as to Medical emergencies do occur in the pedodontic their suitability for management in pedodontic practice 1-4 and one should be prepared, should an practice. Child Patients with severe or unstable event occur in order to rapidly diagnose and medical conditions should be referred for treatment manage the situation. Dental practitioners and their staff need to have appropriate skills, training and equipment available to deal with potentially life b. Training 5,6,7.
threatening conditions. Preparatory steps should Each member of the staff should be trained in BasicLife Support (CPR, Mouth to Mouth Resuscitation, and Heimlich Maneuver). Design an office meeting ambulance and medical practitioner at hand management of medical emergencies should be equipment to administer typed list of drugs Equipment and Drugs.8,9.
PREPARATION FOR EMERGENCIES 6,7
pediatric practice depends upon the expertise and training undergone by the clinician. Drugs must be Prevention6,7
readily available and up-to-date. Assemble allemergency container. They should be stored to facilitate easy treatment of medical emergencies is to prevent identification that can be transported to any area of them from happening. It is recommended that the office within a moment's notice . In most dentists and their staff seek training and regularly emergency situations, it is better to use basic life update their skills in first aid and the treatment of support rather than administer drugs, especially if emergencies. A comprehensive medical history is the dentist is unsure of either dosage, indications of an indispensable part of any patient's record. This use, or method of administration. The doctor should medical history form must be updated regularly. An be familiar with all the medications and their use assessment should be undertaken for child patients well before they are needed. They should be in Issue 2 April – June 2010
Table I- Emergency kit with Drugs and Equipment.
Drug Kit
Critical
 Injectable epinephrine(1:1000, 1:10000)-- I.M./S.C for allergic  injectable antihistamine- Chlorpheniramine maleate 10mg/ml-- I.V.
 Vasodilator -- Glyceryl trinitrate tablets  ammonia vaporole—central respiratory stimulant  Anticonvulsant-- Diazepam emulsion 10mg/2ml Slow I.V  Corticosteroid-- Hydrocortisone sodium succinate 100mg/ml --I.M./I.V –  Antihypoglycemic-- Glucose or dextrose drink, tabs or gel Oral/ Glucose injection 50m1 of 50% I.V./Glucagon 1 mg I.M./S.C.
 Bronchodilator –Salbutamol inhaler/ nebuliserwith nebules 0.1mg/dose2.5mg  Saline 0.9% (for flushes and eye wash) antihypertensive, anticholinergic, respiratory EQUIPMENT
A Dental chair which can be easily changed to a Trendelberg position.
A high volume suction to clear the oral secretions Oxygen cylinder and regulator suitable for delivering high flow oxygen -5L/min for onehour atleast Syringes and needles for drawing up and administering drugs Bag mask device withoxygen reservoir Basic airway adjuncts (oro-pharyngeal and naso-pharyngeal airways) Nebulisor to deliver Salbutamol or adrenaline Advanced airway adjuncts (LMA + endotracheal tubes) Automatic external defibrillator (presently recommended not mandatory) Unconsciousness can be caused by deterioration ofmedical conditions, drug administration or trauma.
Emergency equipment must be readily available in dental practices. The equipment must be checkedfrequently to make sure it is operational. Check theoxygen delivery system regularly to make sure the Many conditions present an immediate threat to life.
cylinder is charged and the mechanism is working.
Almost all of these conditions do so by preventingcirculation and/or oxygenation. The practice of MEDICAL EMERGENCIES – INFORMATION 9-13.
resuscitation is focused on the restoration andmaintenance of circulation and Emergency algorithm , Principles of ‘ A B C’ , ie. A-
restoration of air way, B-
C; Control of bleeding control and
restoration of circulation should be put into force.
unconscious/collapsed patient follows a similar assessment that decides plan of action.
pattern despite the diversity of possible causes.
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who can respond with a few words has a patent airway, can breath and has normal circulation. A check will also indicate any difficulty with breathing person who is unresponsive may have none and is from asthma, heart disease, anaphylaxis. Within 20 at risk of aspiration and airway obstruction. Send an seconds check for breathing and assess for signs of assistant for help. Ask them to then return and circulation. Feel the carotid pulse while looking for confirm the ambulance is on its way.( Appendix I
other signs of life, movement or breathing.
and Appendix II)
Circulation – Assess quickly and if there is no
Airway – Open the airway by head tilt and chin lift.
circulation chest compressions must be started If the casualty is a victim of trauma, then the cervical spine may be damaged, use jaw thrust to compression to stop further blood loss. If circulation open the airway and hold the head to keep the head is absent, the onset of arrest occurred within two and neck still and in alignment with the rest of the minutes, a defibrillator is not immediately available body. Open the airway with chin lift, head tilt or jaw and chest compressions have not already been started, give a single precordial thump. Once ABC consideration to other aspects of emergency care Breathing - The breathing must be assessed
and positioning of the patient/victim. Some patients quickly. If there is no breathing, start rescue may deteriorate after the initial assessment. It is breathing. Consider intubation to protect the airway.
therefore best to consider ABC as a cycle,
If the breathing is inadequate, the rescuer may need performed regularly while awaiting the ambulanceor Issue 2 April – June 2010
Issue 2 April – June 2010
EMERGENCY SITUATIONS : SPECIFIC RESPONSES
headed or dizzy, possibly nauseous, uncomfortable Some of the emergency situations and the Dentists or agitated. They will appear pale and sweaty with response to this situations are discussed here.
increased heart rate. In the syncope stage patient Vasovagal Syncope 5,6,7,15,16
loses consciousness, generalised mucle relaxation Emergencies such as syncope that arise out of followed by seizures. Management depends upon the medical condition of the patient. An other wise threatening and can be managed readily by the alert healthy pedodontic patient does not require medical dental office team. Syncope is usually defined as a intervention: Stop all dental treatment. Remove all transient loss of consciousness and posture due to objects from the patient's mouth. Place patient in cerebral ischaemia caused by a reduction in blood supine position with legs and arms elevated and supply to the brain. Vasodilatation causes pooling head at level of heart. Raise patient’s legs. Follow of blood in the peripheries and vagal stimulation the basic vital life support algorithm and ensure that ABC's are under control. Oxygen can be delivered causes a dramatic fall in blood pressure. The dental at 3-5L/min by nasal canula or 10L/ min by mask.
surgeon is expected to be familiar with the various When consciousness is regained, patient should be etiologies of syncope and should be able to kept flat and reassured. Once pulse and blood pressure recover, slowly raise patient to seated should be able to differentiate the causes of position. Start I.V. fluids, if available. Augment syncope that occurs frequently in a child and that of the adult. In the presyncope stage patient feels light airway every 30 seconds. Patients with significantmedical problems, or when syncope is prolonged or Issue 2 April – June 2010
Causes of Syncope
 Cardiac arrhythmia
 Neurocardiogenic syncope
Vasovagal syncope,Situational syncope ,,Micturitionsyncope,  Syncope
associated
Myocardial infarction, Pulmonary embolism and cardiac output
 Orthostatic hypotension
 Carotid sinus syndrome
 Drug-induced syncope
 Postprandial syncope
continues, have the patient breathe into a small Hyperventilation 5,6,7,16.
paper bag at a rate of 6 to 10 breaths per minute.
Hyperventilation is a fairly common emergency in Do not administer oxygen. Once the episode has the dental office. A patient may hyperventilate due ended, the Dentist and parents should discuss the to extreme anxiety, pain, metabolic acidosis, drug of the attack and address the fears of the use, hypercapnia, cirrhosis, and some central nervous system disorders. The best prevention forhyperventilation is to address any anxieties about hyperventilation the patient's breathing accelerates respiration does not return to normal, transport the and he or she feels as though not enough air is patient to their physician or an emergency room.
getting into his or her lungs. Prolonged rapid deep breathing often in very anxious patients can lead to Airway Obstruction 5,6,7
profound metabolic changes that may result in lossof The small objects like dental burs, endodontic instrument like reamers and files during a dental extremities and around the mouth and lips, muscle procedure can be easily slipped into the esophagus.
twitches,and difficulty in catching a deep breath.
Usually, a conscious patient will swallow the object The patient usually does not lose consciousness or cough it back up as a reflex action. If the object immediately, but prolonged hyperventilation may can pass through the esophagus, it will usually pass lead to convulsions . These symptoms tend to through the entire gastrointestinal tract. It may, increase an anxiety and respiratory rate and depth.
however, lodge somewhere in the tract and cause a Eventually the patient will become unconscious due perforation, an abscess, or a blockage. If the object is aspirated into the lung, it may produce infection, immediately stop all the dental procedures being rendered at the time, and remove all instruments,rubber If an object is dropped, the assistant should patient usually exhibits differing levels of inability to immediately try to aspirate it out with the high speed breathe. Reassure the patient and allow the patient suction. Magill intubation forceps are specially to sit partially or fully upright. Speak calmly to the designed to reach into the pharynx without trauma patient. Try to have the patient regulate his or her breathing in a slower, more even rate. This may dental floss to items like endodontic instruments, pulling on the floss can retrieve it. Use of a rubber Issue 2 April – June 2010
dam is effective in blocking the throat, with a piece inflammatory substances thus precipitating immuneinflammatory response.
Patients will instinctively want to sit up but gravity will work against the object being retrieved and it is more likely to be swallowed. Reposition the dental following: Palpitations, Paresthesia (sensation of chair so the patient's head is down below the chest, pins and needles), Pruritus (itching) and hives, and have him or her turn on their side to try to expel Throbbing in the ears, Coughing, wheezing and the item. If the entire object is retrieved, the patient may be dismissed without radiographs. The patient because of swelling of the tongue and throat.
should be referred to their physician for a follow up Histamine release during immune mechanisms examination. If the object is not retrieved, the patient should be accompanied (by the doctor if possible) to an emergency room or radiology Gastrointestinal symptoms such as abdominal pain, laboratory and further referred to a specialist for cramps, vomiting, and diarrhea are also common.
Histamine causes the blood vessels to dilate (whichlowers blood pressure) and fluid to leak from the Severe or complete upper airway obstruction due to blood volume) resulting in edema and shock. Fluid unconsciousness and cardiac arrest within minutes.
severe enough to cause obstruction of the airway.
cyanotic . This is followed by loss of consciousness.
If there is partial obstruction, encourage the patient arrhythmias. Management depends on the severity to cough up or spit out. Initially do nothing else. If the entry of air is poor due to complete obstructionthere is increasing high pitched stridor, increased Assess the degree of cardiovascular collapse (pulse respiratory distress. In complete airway obstruction and blood pressure). Assess the degree of airway victim cannot speak, breathe or cough.
in the dental chair sit them up, turn patient side on in chair. Support chest with one hand and deliver suspected drug. Immediately call for emergency five sharp back blows between the shoulder blades help. Make the patient lie in supine position. Ensure with the heel of the other hand. If back blows fail, airway is clear . Assess breathing difficulty (stridor, wheeze, can’t speak). Ventilate with oxygen supply emergency help should be summoned. commence airway, breathing, circulation, pulse, blood pressure.
CPR with finger sweep between each cycle.
Prepare for CPR. If the patient is shocked or having emergency help is delayed, doctors trained in signs of bronchospasm, raise the legs to eleate the invasive surgical procedures may opt to perform an Blood Pressure. Administer salbutamol two puffs repeatedly. Adrenaline 0.5 ml, IM, 1:1000 = 0.5 mgshould Anaphylaxis 5,6,7,17
musculature of tongue or floor of mouth. Repeat IM adrenaline every five minutes while waiting for reaction to foreign material. It may present in the tachycardia, bronchospasm. In the dental office,drugs Obtaining a thorough history to identify drug allergy (e.g., H/o allergy to sulpha group of drugs) can to a offending agents. An anaphylactic reaction begins large extent prevent anaphylactic arrack.
drugs that have immunologic in nature. Administer reacts with an IgE type antibody. This reaction drugs orally rather than parenterally when possible.
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When parenteral administration is necessary, keep patients in the office 20 to 30 min after injections Diabetes
Asthma5,6,7,18,19.
The most common diabetic emergencies are due to either extreme on both sides of normality.
bronchial inflammation, smooth muscle spasm and patients on anti-diabetic medications. On the other hand, high blood sugar – hyperglycaemia occurs hypersecretion, all of which compromise bronchial child patients with diabetes are of Type I and elevated blood eosinophil counts. Allergic reactions Hyperglycaemia
are triggering source of the asthmatic attacks.
symptoms include thirst, increased urine output anddehydration. A progressive reduction in conscious Asthmatic attact is sudden in onset with tightness level and hypotension, with coma and cessation of in the chest and commonly with cough, Dyspnea, urine output in severe cases. Management Includes the primary assessment and resuscitation ( ABC) respiration. The termination of attack is commonly circulation.Transport the patient immediately to a stringy mucus. Episodes usually are self-limiting but severe episodes may require medical assistance Hypoglycaemia.
Most asthma-related attacks can be minimised by hypoglycaemia include sweating, hunger, tremor, agitation with progression drowsiness, confusion and coma. Assume any diabetic with impaired attack is acute and severe , patient is unable to consciousness has hypoglycaemia until proven speak in complete sentences, pulse rate will be treated with rapid acting oral carbohydrates, e.g.
greater than 45 per minute. In Life threatening fruit juice, packets of granulated sugar, glucose powder neat or dissolved in water. After ten minutes this short acting carbohydrate should be followed up confusion, agitation can be noticed. If more than one feature severe, or any life threatening, arrange carbohydrate. It is important that the victim is not left alone until all danger of hypoglycaemia has passed.
If the patient is unconscious, attend to the airway, administered as one puff into large volume spacer breathing and circulation. Protect the victim from and allow six breaths, repeated for six times.
Corticoteroids like Prednisone can be given 30-60mg orally.
Epilepsy 5,6,7, 20.
transfer. Repeat Brochidilator therapy.
Epileptic seizure is not a disease but rather a patients on chronic asthmatic treatment will be on significant dosages of corticosteroid therapy. This function that are caused by abnormal activity in the should alert the dentist to the possibility that she is adrenally suppressed and requires an increased manifested by other changes in neurologic function.
necessary to face the emergency situations.
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Table III. GUIDELINES FOR GOOD PRACTICE ON EMERGENCIES IN DENTAL PRACTICE
CONDITION CLINICAL FEATURES TREATMENT/ RESPONSE condition
Clinical features
response /treatment
pulse,palpitations. LA base toxicity -first CNS stimulation then depressionwith convulsions Give orange juice, glucose drink or sugar terminate event ie. loss of consciousness should never occur. If loss ofconsciousness occurs, will needparenteral therapy [glucose orglucagon.] check that respiratory distress not due to May need to repeat dose after 5minutes.
100% oxygen. CPR if cardiac arrestoccurs.
Source: AUSTRALIAN DENTAL ASSOCIATION INC Issue 2 April – June 2010
Evaluation should be directed to the type of patients on phenytoin, phenobarbital, or primidone; degradation of antibiotic accelerated Primary goal is attack. There are several types of epilepsy. In a to prevent self inflicted injuries. Place patient insupine position. Gently, but not forcibly, restrain the major seizure there is a sudden spasm of muscles patient. If possible, place part of a towel or padded producing rigidity (tonic phase). Jerking movements tongue depressor between teeth (to prevent biting of the head, arms and legs may occur (chronic clonic). The victim becomes unconscious and may extending patient's head. Monitor vital signs. Most have noisy or spasmodic breathing, salivation and seizures last two to five minutes, followed by post- ictal phase . During post-ictal phase, the patientmay be confused and recovers over one hour when a convulsion lasts longer than 30 minutes or period . Discharge patient from dental office in the when a tonic-chronic seizure occurs repeatedly.
objects from the mouth and around the patient, e.g.
seizure activity (more than 5 minutes), obtain restraining the patient. The mouth should not be transportation to an emergency room. Administer 5 forced open, nor attempts made to insert any object to 10 mg i.v. diazepam slowly over 1 to 2 minutes.
into the mouth. Turn the victim into a stable side position as soon as the seizure stops,open and CONCLUSION
maintain a clear airway and avoid aspiration. Check It is to conclude that the medical emergencies can happen anywhere. The stressful nature of a dental collapse. Allow the victim to sleep under supervision review chart ( table III) is given for guidance in patient’s medical and drug history will enable dental practitioners to identify those at particular risk of (iv) Any post-seizure respiratory difficulty.
emergencies will still happen and it is recommeded (vi) Post-seizure confusion greater than five that Dental surgeon and his staff members review their current knowledge andskills including the Dental therapy contraindicated for patients with poor control (i.e., more than one seizure per month). If narcotic analgesics necessary, reduce dosage forpatients concurrently receiving CNS depressantdrugs.
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