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Management of Medical

Emergencies in Dental Practice

Anil Kumar1

ABSTRACT:

A medical emergency can occur in dental office, and managing it successfully requires a thorough preparation. The surgeon must know both the physical & emotional status of his patient; this information is as significant for apparently healthy patients undergoing simple exodontia with local anaesthesia as it is for hospitalized & medically compromised patients with complex surgical problems. Careful history recording is a method by which crucial data can be gathered for evaluation. Patients with serious medical illness who also may have a poor understanding of their problems, obtaining a list of medications being taken is often very helpful. An index of suspicion based on sound medical knowledge is of greatest importance in patient evaluation. Appropriate consultation with the participation by the patient's physician may be necessary in certain situations. More extensive history & physical examination, additional laboratory studies, and further consultations are required when the answers to these questions are incomplete. This article highlights the medical emergencies encountered and their management in the dental practice.

Key words: Medical Emergencies, Management

doi: 10.5866/2013.531277

1Graded Specialist Dept of prosthodontics

Command Military Dental Centre Lucknow, India

Article Info:

Received: April 11, 2013

Review Completed: May 12, 2013 Accepted: June 11, 2013

Available Online: October, 2013 (www.nacd.in) © NAD, 2013 - All rights reserved

Email for correspondence: anilks.undefined@gmail.com

Quick Response Code

INTRODUCTION

A medical emergency can be described as any situation in which a patient becomes ill. They may or may not lose consciousness, but ultimately their life may be at risk due to failure of an effective oxygenated circulation to the brain and vital organs. Medical emergencies in dental practice are uncommon but could occur at any time. It is important that dental practitioners are proficient in recognizing them and carrying out initial management of such emergencies.1 The most common emergencies occurring in dental office are:

faints, hypoglycaemia, asthma attacks, anaphylaxis, angina and seizures. These events have been reported to occur on an average once every 3-4 years per dentist.2 The dentist’s role in managing any medical emergency

begins with prevention. This requires that all staff members including dentists, dental hygienists, dental assistants and receptionists be trained for such emergencies. A team approach should be used.3 and each

staff member can play an important role. Appropriate preparation makes this team work effective and improve

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the patient’s chance of achieving good result.4,5

Developing a basic action plan for an unforeseen event is very challenging as there are numerous medical emergencies and numerous protocols to follow. The dentist and the para dental staff should be knowledgeable about all of them. Whenever an emergency develops, the precise diagnosis may not be clear. Without a diagnosis it is impossible to formulate a treatment plan. This problem can be circumvented by following a key principle “the most important objective of nearly all medical emergencies in the dental office is to prevent or correct insufficient oxygenation of the brain or heart [6]. If a patient has lost his consciousness in the dental office it is a result of lack of oxygenated blood in the brain. Management is done by ensuring that oxygenated blood is being delivered to the brain and heart”. This principle has to be followed by the dentist and the paradental staff to put the patient back to normalcy. This is the principle of basic life support also known as cardiopulmonary resuscitation.7 Once the basic principle for

emergency is achieved further management of the actual cause of disease is simplified.

APPROACHES FOR MANAGEMENT OF MEDICAL EMERGENCIES IN DENTAL OFFICE

This article will cover the management of medical emergencies under two headings

1. General/Basic Approach of management of medical emergencies

2. Management of Specific medical emergencies.

Basic approach of management:

The basic goal is directed towards initial management of the patient until he or she recovers fully or till definitive help arrives. Management begins with maintaining ABCs (Airway, Breathing & Circulation). Positioning of the conscious and unconscious patient is very important. If conscious, the patient should be seated in any position that is comfortable. If unconscious, the patient should be supine with the legs elevated slightly to about 100

to 150. This position facilitates blood flow to the brain

thus correcting deficient oxygen delivery.6

Airway assessment is the first step to be followed in any medical emergency. If the patient is conscious this might not be an issue. If the patient is talking, then the airway is patent. In cases of

allergy or anaphylaxis the throat has to be carefully examined to rule out airway compression due to laryngeal edema (a sign of anaphylaxis). Any foreign objects in the oral cavity have to be removed to eliminate the potential for airway blockage or aspiration. If the patient is unconscious patency of the airway is ensured by head tilt and chin lift maneuver as it moves the tongue away from the pharynx, thereby eliminating the obstruction of airway by tongue. This in turn permits oxygenation.

Breathing is the second consideration immediately after airway management. If the patient is unconscious administer two slow deep breaths either mouth to mouth or mouth to nose with each breath lasting one second. The dentist or paradental staff should use a barrier device such as a pocket mask or the mask from a big valve mask device depending on the availability. Check for the chest rise with each ventilation. The clinician should administer rescue breaths at a rate of 10 to 12 per minute for adults and 12 to 20 breaths per minute in adolescents.8

Circulation is the next parameter to be assessed once the breathing procedure has been performed. If the patient is conscious, check the pulse by palpating the radial, brachial or carotid artery. In the unconscious patient, the carotid is the best artery for assessing the pulse. If no pulse is palpable after 10 seconds the dentist or paradental staff has to assume that the patients has experienced cardiac arrest, CPR needs to be initiated. Begin chest compressions at a rate of 100 per minute.8 The

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Management of Specific Medical Emergencies

Specific medical emergencies that can arise in dental practice can be listed as10

1. Vasovagal syncope

2. Hyperventilation/Panic attack 3. Acute asthma attack

4. Anaphylaxis

5. Angina/Myocardial infarction 6. Epileptic seizures

7. Diabetic emergencies 8. Choking and aspiration

9. Adrenal insufficiency

Signs & symptoms * Light headedness/dizzy * Pallor, sweating * Slow pulse rate * Low blood pressure * Nausea /Vomiting * Loss of consciousness

Treatment

* Lay the patient flat and raise the legs to improve venous return

* Maintenance of patent airway by BLS method * Postural hypotension should be ruled out by checking for consumption of ACE inhibitors and angiotensin antagonists. Patients should be advised to rise slowly and take their time.

Vasovagal Syncope (Simple faint)

Loss of consciousness due to inadequate cerebral perfusion and oxygenation is termed as syncope. It is caused mainly because of decreased blood pressure secondary to vagal overactivity. This in turn may follow emotional stress or pain.

Treatment

* Rule out other causes to arrive at a diagnosis of hyperventilation.

* Encouraging the patient to rebreathe their own exhaled air to increase the amount of inhaled carbon dioxide.

Hyperventilation

It is a more common emergency precipitated mainly due to anxiety of the patient. This condition is very distressing to the patient.

Signs & Symptoms

* Breathlessness (respiration rate> 25 breaths/ min)

* Expiratory wheezing

* Use of accessory muscles of respiration

* Tachycardia (heart rate>110/min)

* Cyanosis/slow respiratory rate (less than 8 breaths/min)

* Decreased level of consciousness/confusion.

Drug Route of Equipment for emergency

Administration management

Oxygen Inhalation Portable Oxygen Cylinder with oxygen

face mask and tubing

Glyceryl trinitrate (GTN) spray Sublingual Oropharyngeal airways- sizes 1,2,3 & 4 (400gms per actuation)

Dispersible Aspirin (300mg) Oral (Chewed) Pocket mask with port for oxygen Salbutamol aerosol inhaler Inhalation Portable suction

(100gms per actuation)

Adrenaline injection Intramuscular Single use sterile syringes and needles (1:1000, 1 mg/ml)

Glucagon injection (1 mg) Intramuscular/ 'Spacer 'device for inhaled bronchodilators subcutaneous

Dextrose solution Oral Blood glucose measurement device

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Treatment

* Use of salbutamol inhaler (repeat 2-3 times)

* No response call for ambulance

* 10 litres of Oxygen should be given whilst awaiting transfer. 4-6 actuations from the salbutamol inhaler via a spacer device should be used and repeated every 10 min

* Intramuscular injection of adrenaline if asthma is a part of generalized anaphylactic reaction

Asthma

It is a chronic inflammatory disease of the airways characterized by variable and recurring symptoms, reversible airflow obstruction and bronchospasm.11

Signs & Symptoms * Anxiety

* Light headedness * Dizziness

* Weakness * Paraesthesia * Tetany

* Chest pain/palpitations * Breathlessness

Anaphylaxis

It is a severe life threatening, generalised or systemic hypersensitivity reaction characterized by rapidly developing life threatening airway, breathing and circulatiory problems usually associated with skin and mucosal changes. In dental practice it may be precipitated following the administration of a drug, contact with latex gloves. Symptoms can develop within minutes and early treatment is life saving.

Signs & Symptoms

* Severe crushing pain in the centre and across the chest. Pain may radiate to the shoulders and down the arms into the neck and jaw. * Pale and clammy skin

* Nausea and vomiting * Fall in BP & weak pulse * Shortness of Breath

Treatment

* Patient positioning: In case of breathlessness-sitting position, unconscious- flat position.

* Administer sublingual glyceryl-tri-nitrate spray * Relieving the anxiety of patient by reassuring * Aspirin 300mg orally (crushed or chewed) * Call for ambulance

* High flow oxygen administration (15 litres/min) * Start CPR if patient is unresponsive and check

for vital signs

Myocardial Infarction

It results from the partial interruption of blood supply to a part of the heart causing heart cells to die. This is most commonly due to occlusion of a coronary artery following the rupture of a vulnerable atherosclerotic plaque (unstable collection of lipids and white blood cells) in the wall of an artery.

Epileptic Seizures

Treatment

Signs & Symptoms

* Urticaria, erythema, rhinitis, conjunctivitis * Abdominal pain, vomiting, diarrhoea * Flushing, Pallor

* Laryngeal oedema, bronchospasm causing stridor, wheezing

* Respiratory arrest leading to cardiac arrest

Treatment

* Managing airway, breathing and restoration of blood pressure (laying the patient flat raising the feet and administer oxygen 15 litres/min)

* Intramuscular injection of adrenaline (anterolateral aspect of the middle third of the thigh) in a dose of 500 micrograms (0.5 ml adrenaline injection of 1:1000. Dose repeated at 5 min interval according to BP, pulse and respiratory function.

* Antihistamine drugs and steroids second line drugs

* Salbutamol inhaler in case of asthma precipitation

* Immediate shifting of patient to hospital

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Diabetic Emergencies

Diabetes mellitus is a group of metabolic diseases in which a person has high blood sugar either because the pancreas does not produce enough insulin or because the cells do not respond to the insulin that is produced. In general practice the dentist more likely encounters hypoglycaemia than hyperglycaemia since the latter has a much slower onset. Patients with diabetes should eat normally and take their dose of insulin or oral hypoglycaemic agent before any planned dental treatment. Diabetic control may be adversely affected by oral sepsis leading to risk of complications.12 This article

discusses hypoglycaemia since this is a life threatening situation if precipitated during dental treatment.

Signs & Symptoms

* Brief warning or aura that a seizure is about to occur

* Tonic phase- loss of consciousness, patient becomes rigid and cyanosed

* Clonic phase- Jerking movements of the limbs, tongue may be bitten

* Frothing from the mouth and urinary incontinence

* Seizure often gradually ablates after a few minutes but the patient may remain unconscious and confused once consciousness is regained

* Hypoglycaemia may present as a fit. Blood glucose measurement at an early stage is essential

* Bradycardia (<40 beats/min) leading to drop in blood pressure causes transient cerebral hypoxia and a brief fit which is not true and represents a vasovagal episode

Treatment

* Ensure that the patient is not at risk from injury and make no attempt to put anything in the mouth or between the teeth.

* Do not insert any airway adjunct while the patient is actively fitting

* Administer high flow oxygen (15 litres/min) * Place the patient in the recovery position and

reassess after the convulsive movements have subsided

* Start CPR if the patient remains unresponsive after the fit

* Administer oral glucose if the blood glucose is <3.0 mmol/litre

* If seizures are prolonged Midazolam via the buccal or intranasal route is administered. Dose: 1-5 yrs:5mg, 5-10 yrs:7.5mg, >10yrs:10mg

Signs & Symptoms * Cough and splutter * Difficulty in breathing

* Noisy breathing with wheeze or stridor * Paradoxical chest or abdominal movements * Cyanosis and loss of consciousness

Signs & Symptoms * Shaking & trembling * Sweating

* Headache

* Slurring of speech

* Aggression and confusion * Seizures

* Unconsciousness

Treatment

* If the patient is conscious administer oral glucose (2-4 teaspoons of sugar)

* If the patient is unconscious administer 1 mg glucagon intramuscularly or subcutaneously * Call for ambulance if the patient does not

respond

* Administer 20ml of intravenous glucose solution (20-50%) under medical supervision if patient do not respond to glucagon.

* Check for vital signs and start CPR

* Once the patient regains consciousness and has intact gag reflex he/she should be given oral glucose and a high carbohydrate food.

Choking and Aspiration

Patients undergoing dental treatment are more susceptible to choking with the potential risk of aspiration. Prevention is important by the use of rubber dam, instrument chains and mouth sponges. Careful suction of the oral cavity and close observation minimizes the risk.

Adrenal Insufficiency

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Local Anaesthetic Emergencies & Bleeding Disorders

Emergencies under this section include mainly those patients who are allergic to local anaesthesia. Management is similar to treatment of anaphylaxis. Fainting in association with the injection of local anaesthetic is more common and can be avoided by administering the local anaesthetic while the patient is supine.10

Treatment

* Vigorous coughing in cases of aspiration * Salbutamol inhaler for treating wheeze * If large pieces of foreign material have been

aspirated refer the patient to hospital for chest X-ray and removal

* Five sharp back blows to be delivered by standing to the side of the victim and slightly behind. The chest should be supported with one hand and the victim leant well forwards so that when the obstruction is dislodged it is expelled from the mouth rather than passing down the airway

* If back blows fail upto five abdominal thrusts should be given. Stand behind the patient and put both arms around the upper part of their abdomen and lean forwards. The rescuer’s fist should be clenched and placed between the umbilicus and lower end of the sternum. The clenched fist should be grasped with the other hand and pulled sharply inwards and upwards.

Emergency Dental Care –In case of alleged allergy to LA

Option 1 - General anaesthesia to manage dental emergencies

Option 2 - Histamine blocker: use of histamine blocker – diphenhydramine as a local anaesthetic for management of pain during treatment. Most injectable histamine blockers possess local anaesthetic properties.

Bleeding disorders

Patients with a history of bleeding problems caused by disease or drugs should be managed so as to minimize the risk of hemorrhage.

Signs & Symptoms * Loss of consciousness

* Rapid, weak or impalpable pulse * Fall in blood pressure

Treatment

* Administration of steroid booster dose prior to treatment to prevent adrenal insufficiency. Doubling the patient’s steroid dose before dental treatment under local anaesthesia is advised9

* If the patient is unconscious start CPR and call for an ambulance.

Bleeding disorders maybe classified into coagulation disorders, thrombocytopenic purpuras or non thrombocytopenic purpuras.

Coagulation disorders

The main inherited coagulation disorders include hemophilia’s A and B and von Willebrand’s disease. Hemophilia A results in a deficiency of coagulation factor VIII and clinical severity depends on level of factor VIII remaining. Severe haemophiliac with less than 1% of normal factor VIII levels may have severe bleeding on slightest provocation, whereas moderate haemophiliacs (1 to 5% factor VIII) have less frequent spontaneous hemorrhage but bleed with minimal trauma. Mild hemophilia’s (6-30%) after severe trauma or during surgical procedure. Hemophilia B or Christmas disease results in deficiency of factor IX. Von Willebrand’s disease results from a deficiency of von Willebrand’s factor which mediates adhesion of platelets to the injured vessel wall and is required for primary hemostasis.

Thrombocytopenic Purpura

Platelet count is less than 1,00,000/mm3.

Bleeding due to thrombocytopenia may be seen with idiopathic thrombocytopenic purpura, radiation therapy, leukaemia or infections. Purpuras are hemorrhagic disease characterized by extravasation of blood into tissues under the skin or mucosa, production of petechiae or ecchymosis.

Non Thrombocytopenic purpura

Occurs as a result of either vascular wall fragility or thrombasthenia (impaired platelet aggregation). Vascular wall fragility results from hypersensitivity, scurvy, infection etc. Thrombasthenia occurs in uraemia, aspirin ingestion etc.

Patients on anti-coagulant therapy

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Prevention

The most important factor in identifying patients with potential defects in hemostasis is patient history. Patient should be asked about any past abnormal bleeding. Also physical examination to detect any petechiae or ecchymosis.

Laboratory tests to evaluate patients with suspicion of abnormal hemostasis.

Prothrombin time – normal value is 11-14 seconds.

Partial thromboplastin time - Usually elevated with haemophilia A, B, C and von Willebrand’s disease. Normal is 25-30 seconds.

Platelet count - Evaluates the number of platelets present. Normal platelet count is between 1, 50,000 and 400,000/mm3.

Spontaneous bleeding occurs at platelet count < 20,000/mm3. Bleeding time- Normal range is 2-5 minutes.

Conclusion

Management of medical emergencies in dental office can be done only by correct diagnosis of the situation. The first priority of the dentist and paradental staff in managing any medical emergency is to keep the victim alive until they recover or till the time advanced medical care is given to the patient. The ultimate goal of the dentist is to prevent the death of the victim which is achieved through prompt recognition and effective management of the emergency. This review article has covered the approach that has to be followed by the dentist and the paradental staff in dealing with commonly occurring medical emergencies in the dental practice.

Management

* Prevention of untoward bleeding

* No surgical procedures should be performed on a patient suspected of having a coagulation disorder. Haematologist has to be consulted before treating the patient

* I f all the preventive measures fail to identify a haemostatic disorder, the first indication of the problem may be prolonged bleeding following a dental procedure

* Firm manual pressure should be applied with a moist gauze pack for 5 minutes over the bleeding site.

* If local pressure is inadequate to control bleeding, topical haemostatic agents should be employed to augment the pressure. Oxidised cellulose physically absorbs blood and promotes clot formation. Gelfoam can also be used to arrest bleeding.

* Antifibrinolytics for maintenance of clot stability are important to prevent bleeding. Epsilon aminocaproic acid (EACA) 50-60mg/kg every 4 hrs orally or Tranexamic acid as a topical agent are used.

References

1. Mark Greenwood. Medical Emergencies in Dental Practice: 1. The Drug Box, Equipment and General Approach. Dent Update 2009;36:202-211.

2. Atherton GJ, McCaul JA, Williams SA. Medical emergencies in general dental practice in Great Britain. Part 1: their prevalence over a 10-year period. Br Dent J 1999;186:72-79.

3. Malamed SF. Preparation. In: Medical emergencies in the dental office 6th ed. St Louis: Mosby;2007:59-65.

4. American Heart Association Part 3; effective resuscitation team dynamics. In: Advanced Cardiovascular Life Support Provider Manual: Professional Dallas: American Heart Association;2006:11-17.

5. Gaba DM, Fish KJ, Howard SK. Principles of anesthesia crisis resourcs management. In:Crisis Management in Anesthesiology Philadelphia: Churchill Livingstone. 1993:31-52.

6. Daniel A. Haas. Preparing dental office staff members for emergencies: Developing a Basic Action Plan.JADA 2010;141(1):8S-13S.

7. American Heart Association Part 2: the systematic approach- the BLS primary survey and ACLS secondary survey. In: Advanced cardiovascular life support provider manual: Professional.2006:7-10.

8. American Heart Association Part 3: overview of CPR. Circulation 2005;112:IV-18.

9. Medical Emergencies and Resuscitation Standards for Clinical Practice and Training for Dental Practitioners and Dental Care Professionals in General Dental Practice- A statement from the Resuscitation Council (UK), London, July 2006. Revised May 2008.

10. Mark Greenwood. Medical Emergencies in Dental Practice: 2. Management of Specific Medical Emergencies. Dent Update 2009;36:262-268.

11. NHLBI Guidelines 2007:11-12.

References

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