Dr. Esam Ahmad Z. Omar BDS, MSc-OMFS, FFDRCSI

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1 Dr. Esam Ahmad Z. Omar BDS, MSc-OMFS, FFDRCSI Emergency in Dental Clinic & Assistant Professor Oral & Maxillofacial Surgeon 1 2 Importance of Taking good Medical History of the Unconscious Patient in Dentistry The first line is prevention by following the medical protocol of each condition 3 4 Definition Syncope is a temporary loss of consciousness due to cerebral ischaemia Coma is a state of unconsciousness from which a patient cannot be aroused Topics to be discussed General management of an unconscious patient (Basic Life Support) Syncope : causes and management Coma : causes, assessment and management 5 6

UNCONSCIOUS PATIENT BASIC LIFE SUPPORT AIRWAY BREATHING CIRCULATION AIRWAY Head tilt /

Airway maintenance oropharyngeal (Guedel) airway nasopharyngeal airway laryngeal mask

Check for chest movements / air movements from nose If absent, start ventilation

2 UNCONSCIOUS PATIENT BASIC LIFE SUPPORT AIRWAY BREATHING CIRCULATION AIRWAY Head tilt / Chin lift Foreign body clearance finger sweep suction apparatus fixed / portable Airway maintenance oropharyngeal (Guedel) airway nasopharyngeal airway laryngeal mask airway tracheal intubation 7 8 Airway Obstruction Head tilt 9 10 Chin lift BREATHING Check for chest movements / air movements from nose If absent, start ventilation (external air respiration (EAR) / oxygen) Mouth - mouth Mouth - nose Mouth - mask intubation 11 12

3 Mouth to mouth Laerdal Pocket Mask CIRCULATION Pulse Palpate carotid pulse If absent, start chest compressions: external chest compressions praecordial thump Ambu-Cardio pum Co-ordination of Ventilation and Chest Compressions 15 5 Recovery position

4 CAUSES OF SYNCOPE 1. Faint (vasovagal attack) 2. Postural hypotension 3. Hypoglycaemia 4. Corticosteroid insufficiency 5. Severe haemorrhage 6. Acute cardiac failure; cardiac arrest, heart block (Stokes-Adams attacks) 7. Stroke 8. Epilepsy 9. Anaphylaxis Faint Clinical Features dizziness nausea pallor cold, moist skin (clammy) pulse initially slow and weak Faint Anxiety Pain Fatigue Fasting High temperature Faint lower patient s head +/- smelling salts lie flat Postural hypotension dizziness / loss of consciousness when patient comes upright after a period lying down rapid recovery (within seconds) reverse can occur in pregnancy: supine hypotensive syndrome 23 24

flat again Bring upright very slowly 25 26 Hypoglycaemia Hypoglycaemia may developed in normal person 27 28

5 Postural hypotension Predisposing factors rapidly bringing patient upright from lying down prolonged periods of lying down elderly patients atropinic drugs anti-hypertensives, tricyclic antidepressants Postural hypotension Lay patient flat again Bring upright very slowly Hypoglycaemia Hypoglycaemia may developed in normal person Hypoglycaemia Hypoglycaemia rapid onset drowsiness disorientation irritability, aggression warm, moist skin pulse full and rapid 29 30

Hypoglycaemia lack of food too much insulin excessive exercise Hypoglycaemia lie patient flat if possible give glucose orally glucose drink / hypostop or IV 50ml 50% glucose 31 32 The number of

6 Hypoglycaemia lack of food too much insulin excessive exercise Hypoglycaemia lie patient flat if possible give glucose orally glucose drink / hypostop or IV 50ml 50% glucose The number of people using cortisone has been increased Significantly within the last few year weakness nausea +/- vomiting pulse weak and rapid falling blood pressure that does not respond to lying the patient flat physiological / psychological stress infection trauma severe vomiting operation ADRENAL CRISIS 35 36

7 Prevention If the patient currently taking steroid therapy of the steroid has been given during last three months: Supplementation should be given: 25 mg. IV No need from given high dose (200mg. IV) (Hydrocortisone Sodium succinate, 25mg. IV) Asking the patient from taking double dose is used by some clinician>>> Should be avoided 37 Time since last course Dose of prednisolone Type of Surgery > 3 months Not needed N/A N/A Cover Needed < 3 months <10 mg/day Not needed Not needed < 3 months >10 mg/day Restorative or single extraction Multiple extraction Moderate Surgery under GA The daily dose or 25mg HCSS 25mg HCSS IV +Daily Dose 100mg/day for 24 h. and for 72 h. for major Max. Fax. eg. oncology 38 lay patient flat, with legs raised give methylprednisolone 500mg / hydrocortisone 500mg IV give oxygen summon medical assistance Haemorrhage falling blood pressure rising pulse rate Haemorrhage life threatening haemorrhage is very unlikely from oral / peri-oral vessels may follow: damage to maxillary artery after radical neck dissections, erosion of carotid artery under an infected flap Bleeding tendency Capillaries Platelets Clotting factors Anti-coagulant 41

Heamophilia A Heamophilia A In major maxillofacial surgery: Should be elevated to 100% X= % rise in factor VIII X weight KG K(K= 1.5 for factor VIII) In Minor Oral Surgery: DDAVP= 0.

Should be avoided in: 1) Cardiovascular Diseases 2) Poor renal Function To avoid fluid overload 43 44 Physiology- Oral Anticoagulants INR PTR= PT.

8 Heamophilia A Heamophilia A In major maxillofacial surgery: Should be elevated to 100% X= % rise in factor VIII X weight KG K(K= 1.5 for factor VIII) In Minor Oral Surgery: DDAVP= 0.4 Ugs/kg Tranexamic 30mg/kg.. Can be given as mouth wash 4.8% for 7 days/ for times a day DDAVP. Should be avoided in: 1) Cardiovascular Diseases 2) Poor renal Function To avoid fluid overload Physiology- Oral Anticoagulants INR PTR= PT. normal PT of the lab INR=(PTR)ISI Haemorrhage prevent further blood loss by direct pressure take blood for haemoglobin levels, blood-grouping and cross-matching set up an IV infusion if indicated, transfuse to restore blood volume Cardiac arrest Myocardial infarction hypoxia anaesthetic overdose Cardiac arrest cessation of respiration absence of arterial pulses pallor / cyanosis ABSENT CAROTID PULSE DILATED PUPILS UNCONSCIOUSNESS APNOEA / AGONAL GASPS DEATH-LIKE APPEARANCE 47 48

9 Cardiac arrest summon medical assistance start CPR Stroke hemiplegia Predisposing factors hypertension Maintain airway Epilepsy AURA TONIC PHASE widespread jerking +/- incontinence CLONIC PHASE RECOVERY Epilepsy Predisposing factors epileptogenic drugs tricyclics, phenothiazines, alcohol, enflurane, methohexitone fatigue starvation / hypoglycaemia stress infection flickering lights menstruation Epilepsy maintain airway and oxygenation if not recovered within 5 minutes give diazepam 0.1mg/kg IV or midazolam 2mg IV every minute if status epilepticus give up to 800mg chlormethiazole IV ( drops / minute) Anaphylaxis cold, clammy skin pulse weak and rapid oedema / urticaria / wheeze acutely falling blood pressure 53 54

10 Anaphylaxis Anaphylaxis exposure to allergen, e.g. penicillin Anaphylaxis lay patient flat give 1:1000 adrenaline IM Give hydrocortisone sodium succinate mg IM or methylprednisolone 500mg IV give oxygen summon medical assistance Suspected Drug Reaction symptoms / signs variable confusion, drowsiness, fits or loss of consciousness CAUSES OF COMA 1. Trauma (raised ICP) 2. Hypoxia 3. Hyperglycaemia 4. Infections (pneumonia) 5. Drug poisoning 6. Uraemia 7. Alcohol excess 8. Hepatic encephalopathy 9. Tumour 59 60

11 of a Comatosed Patient Quick examination (primary survey) IV access Quick history Detailed examination (secondary survey) Treat underlying cause END Thank you The Royal College of Surgeons Dr. Esam Ahmad Z. Omar BDS, MSc-OMFS, FFDRCSI 63 64

Medical Emergencies and Current Management in Dentistry. Prof. Mark Greenwood Newcastle University

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