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Good morning

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MEDICAL EMERGENCIES IN DENTAL PRACTICE

Presented By

Deepika Jasti

1st year PG

Public Health Dentistry

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Contents • Introduction • Classification of medical

emergencies• ASA physical status classification

system• Dental office emergency team• Basic action for every emergency • Most common emergencies and

their Management • Syncope • Postural hypotension • Acute adrenal insufficiency • Hyperventilation• Status asthmatics

• Diabetic emergencies• Epilepsy• Anaphylactic reactions• Angina pectoris • Myocardial infarction• Cardiac arrest • Basic emergency kit• Basic emergency drugs • Emergency management at camps• Conclusion • Recent studies conducted in India • References

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Introduction

The emergency is derived from the Latin, meaning to dip, Plung, Indundate, engulf or to bury.

Definition: A serious and unexpected situation requiring immediate action.

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WHY WE SHOULD READ THIS SEMINAR

“When you prepare for an emergency, the emergency cease to exist”

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Classification of medical emergencies

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ASA Physical Status Classification System

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Dental Office Emergency Team

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Basic action for every emergencyt/B

RR

UNCONSCIOUS - Look-Listen-Feel

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Most common emergencies

• Syncope • Postural hypotension • Acute adrenal insufficiency • Hyperventilation• Status asthmatics• Diabetic emergencies• Epilepsy• Anaphylactic reactions• Angina pectoris • Myocardial infarction• Cardiac arrest

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Syncope

Syncope is defined as a transient loss of consciousness and postural tone due to reduced cerebral flow and is associated with spontaneous recovery

Temazepam 5mg orally

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Postural Hypotension/

• Definition: postural hypotension is defined as a drop in systolic blood pressure of 30 mm Hg or greater or a 10 mm Hg or greater fall in diastolic blood pressure that occurs on standing.

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•Risk factors•Clinical features - %BPangina, lethargy, low back ache •Diagnosis •Management Assessment of consciousness P-A-B-C-DFludrocortisone – to raise BP Discharge- Chair position

Postural Hypotension

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Acute Adrenal Insufficiency

• 25 steroids• Cortisole regulates BP and glucose utilisation. K,ca • Signs and symptoms- how to diagnose• Management – 5-10l/min oxygen

mix-o-vial

100 mg

2ml liquidHydro

cortisone

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Foreign Body Obstruction

Universal choking sign

Heimlich manever

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Hyperventilation

Definition : Hyperventilation is defined as ventilation in excess of that required to maintain normal blood oxygen and carbon dioxide partial pressures.

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Respiratory alkalosis – Hypocapnia

Vasoconstriction in cerebral blood vessels

Feeling of tightness in chestRelease of catecholamines due to

anxiety Respiratory alkolosis – change in

blood pH – alters calcium.

Management P-A-B-C-D

Calm the patientBreath 4-5 times

Co2 -02 Paper bags

Diazepam/ midazolam

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Status Asthmaticus

Hypercapnea –acidosis-respiratory failure

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Status Asthmaticus

Salbutamol -250mg iv

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Diabetic Emergencies

25-50 ml1mg

15 grms

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EPILEPSY

• Definition: disorder of brain characterized by an enduring predisposition to generate epileptic seizures and by the neurobiological, cognitive, psychological and social consequences of this condition.

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Classification

Partial seizureSimple partial seizureComplete partial seizurePartial seizure with secondary generalization

Primarily generalized seizuresAbsence seizure (petitmal seizure)Tonic clonic seizure (grandmal seizure)Tonic seizureAtonic seizureMyoclonic seizure

Unclassified seizuresNeonatal seizuresInfantile seizures

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Precipitating factorsSignsManagementStatus epilepticus – 15 min

D/M= 10/5

Tonic phase

Clonic phase

Flaccidity

Incontinence

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 Anaphylactic Reactions

10-20 Mg 10ml blood

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Myocardial Infarction

50/50 Nitrous oxide and

oxygen

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Cardiac Arrest 4-5cm80/min50kgs

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Basic emergency kit

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Basic emergency kit

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Basic emergency drugs

• Oxygen • Epinephrine • Nitroglycerin • Injectable

antihistamine • Salbutamol • Aspirin • Oral carbohydrate • Glucagon • Atropine

• Corticosteroid • Morphine • Naloxone • Nitrous oxide • Injectable

benzodiaepine• Flumazenil• Aromatic ammonia

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 Emergency Management At Camps

To be forewarned is to be forearmed

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Medico legal considerations

The standard of care can be defined as “what the reasonable, prudent person with the same level of training and experience would have done in the same or similar circumstances.”

“Ignorance of the law does not constitute immunity from liability”

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Recommendations

• When an emergency arises call for EMS immediately • If there is a problem, such as a dental dam clamp falling

into a patient’s throat, be honest with patients as to the nature of the problem.

• Refer patients to medical professionals when necessary. Never attempt to treat situations which require physician or hospital management.

• Be knowledgeable about state dental practice acts and your requirements for dealing with emergencies

• Current basic life support certificate for all dental office staff

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• Take a complete health history for new patients and update it at each visit. Maintain adequate records. Document emergency treatment rendered; generally, courts have maintained that if it wasn’t written down, it wasn’t done.

• Take vital signs, especially if an anesthetic is to be administered.

• Having an emergency kit in the office does not prevent liability unless you know how to use it properly.

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Conclusion

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 Recent studies conducted in India

• Gupta et. al, preparedness of management of medical emergencies among dentists in Udupi and Mangalore, India. J. contemp dent practice 2008; 9(5); 92-9.

• Praveen et al, evaluation of knowledge, experience and perceptions about medical emergencies amongst dental graduates of Bangalore city, India. J clin expt dent. 2012; 4(1); 14-8.

• Mainak saha et al, emergency preparedness; a survey of dental practitioners in Indore: JIDA, vol. 5, no. 12, dec 2011.

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 Recent studies conducted in India

• Bhavana et al, a survey of medical emergencies in dental practice in India. Paper presentation at 9th world congress on preventive dentistry, 2009.

• Mohan das et al, knowledge, attitude and practice in emergency management of dental injury among physical education teachers: a survey in banglore urban schools. Dent update, 2009, may, 36(4): 202-4. 207-8. 211.

• Santa et al, awareness of basic life support among medical, dental , nursing students and doctors. Indian J. Anaesth. 2010, March-April; 54 (2); 121-126.

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• Gupta T et al, in 2008 conducted a study to assess the preparedness for management of medical emergencies among dentists in the cities of Udupi and Mangalore in India and found that Less than half (42.1%) of the dentists reported having received practical training in management of medical emergencies during their undergraduate and postgraduate education. Only about one-third of the respondents felt competent in performing mouth-to-mouth breathing (39.3%), cardiac compression (35.2%), foreign body obstruction relief (32.8%), and in administering IV drugs (34.5%) or supplemental oxygen (27.4%). The most commonly available emergency drugs in treatment areas were oral glucose (82.2%) and adrenaline (65.8%).

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However, less than one-fourth of the respondents had the following on hand in their treatment facility: oxygen (24.0%), an AMBU bag (17.1%), pocket mask (13.0%), bronchodilator spray (24.7%), diazepam (20.5%), aspirin (20.5%), and glyceryl trinitrate (17.8%). Less than half (39%) of the respondents reported having clinical staff members trained to assist in emergency recognition and management and only 5.8% carried out emergency drills in their workplace.

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Santa et al in 2010, conducted a cross sectional study to assess the awareness of Basic Life Support (BLS) among students, doctors and nurses of medical, dental, homeopathy and nursing colleges and found that no one among them had complete knowledge of BLS. Only two out of 1054 (0.19%) had secured 80 - 89% marks, 10 out of 1054 (0.95%) had secured 70 - 79% marks, 40 of 1054 (4.08%) had secured 60 - 69% marks and 105 of 1054 (9.96%) had secured 50 - 59% marks. A majority of them, that is, 894 (84.82%) had secured less than 50% marks. Thus it is concluded that awareness of BLS among students, doctors and nurses of medical, dental, homeopathy and nursing colleges is very poor.

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References

1. Stanlet F. Malamed, Medical emergencies in dental office, 6th ed. page no: 12, 38, 60.

2. Medical emergencies in dentistry : Prevention and Preparation, dentistry Iq, articles, volume-2, issue -10

3. Haas DA et al., Preparing dental office staff members for emergencies: developing a basic action plan, J Am Dent Assoc, 2010 May;141 Suppl 1:8S-13S.

4. Harrison’s text book of principles of internal medicine, vol. 1, 18th ed.

5. www.dentallearning.org/course/fde0011-10/coursebook_ch09.pdf

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6. Phil Jevon et al., Postural hypotension: symptoms and management, nursing times, vol: 97, issue: 03, PAGE NO: 39.

7. Lapointe et al, Pocket guide to medical emergencies in dental office. www.faculty.ksu.edu.com

8. cowson’s text book of oral pathology and oral medicine , Emergencies in dental practice, – 7th ed. page no ; 385-390.

9. Burket’s text book of oral medicine: diagnosis and treatment, page no. 519.

10. Fisher et al., epileptic seizures and epilepsy: definitions proposed by International league against epilepsy (ILAE) and the international bureau for epilepsy (IBE), Epilepsia, Vol.46, No.4, 2005.

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11. Harrison’s principles of internal medicine, volume II, 16th ed. page no: 2357.

12. Kenneth et al, Allergy & Anaphylaxis, Inside Dentistry, March 2011, Volume 7, Issue 3

13.Daniel A Haas et al., Management of Medical Emergencies in the Dental Office: Conditions in Each Country, the Extent of Treatment by the Dentist, Anesth Prog. 2006 Spring; 53(1): 20–24.

14.Rosenberg M et al., Preparing for medical emergencies. The essential drugs and equipment for the dental office JADA, Vol. 141, May 2010.

15.Roberson et al., Are You (and Your Staff) Prepared for a Medical Emergency?, fall 2009, vol 12, no.2

16.Office emergencies and emergency kits. JADA march 2002, vol 133.

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Thank you