QUICK REFERENCE TO DENTAL OFFICE EMERGENCIES --------------------------------------- Prepared By Dr. Mahmoud H. Al-Johani info@saudident.com 2003 AD

CONTENTS 1 INTRODUCTION 2 2 SYNCOPE (FAINTING) 3 3 POSTURAL HYPOTENSION 3 4 AIRWAY OBSTRUCTION 3 5 HYPERVENTILATION SYNDROME 4 6 BRONCHIAL ASTHMA 4 7 LOCAL ANESHTETIC OVERDOSE 5 8 ANAPHYLACTIC SHOCK 5 9 SEIZURE DISORDER 6 10 CEREBRAL VASCULAR ACCIDENT (CVA) 6 11 ANGINA PECTORIS 6 12 INSULIN SHOCK 7 13 DIABETIC ACIDOSIS 7 14 ADRENAL INSUFFICIENCY 8 15 REFERENCE 9 PAGE Mahmoud H. Al-Johani, BDS, www.saudident.com 1

INTRODUCTION Most life-threatening office emergencies are caused by the patient s inability to withstand physical or emotional stress or the patient s reaction to drugs. Emergencies also can be caused by a complication of a pre-existing systemic disease. The best management of emergency is prevention. Dental practitioners must be prepared to treat the seemingly well but chronically ill patient whose condition is managed by a variety of drugs. The dentist must be trained in providing basic cardiac life support (BCLS) and in many cases advanced cardiac life support (ACLS). The dentist should be prepared to provide resuscitative procedures in emergency situations but should give even more consideration to preventing them. This can be accomplished by obtaining an adequate history of the patient, making an appropriate physical evaluation, and ensuring that the patient and environment are prepared before treatment. Mahmoud H. Al-Johani, BDS, www.saudident.com 2

1- SYNCOPE (FAINTING) Decreased circulation of the blood to the brain.! Pallor! Anxiety! Nausea! Moist, cool skin! Diaphoresis! Rapid pulse (Tachycardia)! Loss of consciousness! Decreased blood pressure! Dilatation of pupils! Place pt. in supine position, with feet slightly elevated! Maintain airway! Establish verbal encouragement of pt.! Administer oxygen! Place crushed ammonia carpule under nose! Apply cold compress to face and neck! Reassure and comfort pt. 2- POSTURAL HYPOTENSION Syncope in moving from the supine to upright position! Place pt. in supine position! Maintain airway; check breathing! Oxygen (as needed)! Reposition pt. slowly, after stable 3- AIRWAY OBSTRUCTION Foreign body in larynx or pharynx! Choking! Gagging! Violent expiratory effort! Substernal notch retraction! Cyanosis! Labored breathing! Rapid pulse initially, then decreased pulse! Cardiac arrest! Place pt. in supine position! Tilt head backward! Clear airway manually of debris (suction oral cavity)! Check for respiratory sounds; ventilate if necessary! Administer oxygen Mahmoud H. Al-Johani, BDS, www.saudident.com 3

! Perform Heimlich maneuver, if needed! Place oropharyngeal or nasopharyngeal airway, if obstruction is visible, try to dislodge! Perform cricothyrotomy, if unable to clear airway! If foreign body passes, refer immediately to radiographic examination! Child: Small child may be held upside down and four sharp blows delivered between shoulder blades Heimlich maneuver: the pt. is encircled by your arms from behind at the level of the lower border of the rib cage; a sudden forceful squeeze is exerted by pulling your arms together with the hands directed upwards towards the chest. 4- HYPERVENTILATION SYNDROME Excessive loss of carbon dioxide, producing respiratory alkalosis.! Rapid, shallow breathing! Confusion! Vertigo (dizziness)! Paresthesia (numbness or tingling of extremities)! Carpo-pedal spasm! Position pt. semi-reclining! Calm and reassure pt. vocally! Instruct pt to breathe carbon dioxide enriched air through rebreathing bag! Do not administer oxygen! Administer medication to calm pt, if needed 5- BRONCHIAL ASTHMA Spasm and constriction of the bronchi! Labored breathing! Wheezing! Anxiety! Cyanosis! If severe, inability to speak! Position pt. semi-reclining! Allow the pt to use his/her own inhaler! Administer bronchodilator-mistometer! Administer oxygen! Administer parenteral medications: - Adult: I.M. epinephrine 1:1000 0.3 ml, repeat if necessary - Children: I.M. epinephrine 1:1000 0.1 ml, repeat if necessary! Administer hydrocortisone sodium succinate 100 mg I.V.! Urgent transfer to hospital Mahmoud H. Al-Johani, BDS, www.saudident.com 4

6- LOCAL ANESTHETIC OVERDOSE Excitement of CNS followed by depression! Apprehension! Anxiety! Restlessness! Confusion! Tremors! Rapid breathing! Rapid heart rate Mild Rxn! Administer oxygen, if needed! Administer anticonvulsant drug, if needed (ie. Valium)! Medical consult, if necessary Severe Rxn! Place pt. in supine position! Suction mouth and throat! Manage seizures! Provide basic life support! Administer anticonvulsant drug, if needed! Manage post-seizure depression 7- ANAPHYLACTIC SHOCK Allergic Rxn! Progressive respiratory and circulatory failure! Itching of nose and hands! Flushing face! Feeling of substernal depression! Labored breathing, wheezing! Coughing! Sudden hypotension! Cyanosis! Loss of consciousness! Incontinence! Place pt. in supine position! Clear airway! Administer oxygen and ventilate manually, if necessary! Administer aqueous epinephrine 1:1000, 0.2-0.5 ml I.M or S.C. (Children: 0.125-0.25 ml I.V.)! Start I.V. fluids (1000 ml or 500 ml of D 5 W or Ringer s lactate)! Give aminophylline 250 mg I.V. very slowly! Apply tourniquet to injection site! Transfer pt. to hospital Mahmoud H. Al-Johani, BDS, www.saudident.com 5

8- SEIZURE DISORDERS Intermittent disorder of nervous system caused by sudden discharge of cerebral neurons Idiosyncracy to drug! Excitement, tremor, followed by clonic-tonic convulsions! Trance-like state! Place pt. on floor! Loosen clothing and ensure safety of pt.! Maintain airway! Administer Valium 5-20 mg I.V. until cessation of seizure! Be prepared for postseizure depression; support respiration 9- CEREBRAL VASCULAR ACCIDENTS (CVA) Obstruction of blood vessel of brain! Weakness! Confusion! Headache! Dizziness! Dysphagia! Vital signs usually satisfactory! Aphasia! Nausea! Paralysis! Loss of consciousness Transient Ischemic Attack! Obtain medical consult with physician CVA (Conscious pt.)! Position pt. semi-reclining! Seek medical assistance CVA (Unconscious pt.)! Place pt. in supine position! Record vital signs! Provide basic life support! Transfer to hospital 10- ANGINA PECTORIS Insufficient blood supply to cardiac muscle May be precipitated by stress or anxiety! Pain in chest! Vital signs satisfactory! Pt. history of angina; pain persists 3-5 minutes! Position pt. semi-reclining! Administer oxygen! Administer nitroglycerin 1/150 gr sublingually (may be repeated in 5 minutes)! Reassure pt Mahmoud H. Al-Johani, BDS, www.saudident.com 6

! Establish verbal encouragement! If history of angina or pain does not subside, suspect myocardial infarction! Urgent transfer to hospital 11- INSULIN SHOCK Hypoglycemia or hyperinsulinism! Nervousness! Confusion! Profuse sweating! Sudden onset! Normal, rapid breathing! Drooling from mouth! Full and bounding pulse! Convulsion! Moist, pale skin! Coma! Administer oral sugar with orange juice! If unconscious, administer 50% dextrose I.V 12- DIABETIC ACIDOSIS Hyperglycemia, insufficient insulin in the body to metabolize carbohydrates and fats! Gradual onset! Dry, flushed skin! Dry mouth, intense thirst! Deep, labored breathing! Confusion! Disoriented! Stuporous! Sweet breath! Coma! Call for medical assistance! Position pt. semi-reclining! Maintain airway, administer oxygen! Start I.V. and administer lactated Ringer s! Keep warm! Administer basic life support! Transfer to hospital NB. If a diabetic pt. collapse, assume hypoglycemia unless you are certain the cause is hyperglycemia. You will not worsen any hyperglycemia by giving glucose or glucagons, but failure to raise the blood sugar level in hypoglycemia may be potentially fatal! Mahmoud H. Al-Johani, BDS, www.saudident.com 7

13- ADRENAL INSUFFICIENCY Insufficient corticosteroid output during a stimulus such as a stressful dental situation or infection! Weakness! Pallor! Cardiovascular attack! Perspiration! Thready, rapid pulse! Administer oxygen! Send for medical assistance! Administer Decadron 4mg I.V. to adults, 1-4 mg I.V. to children Mahmoud H. Al-Johani, BDS, www.saudident.com 8

REFERENCE! Stanley F. Malamed. Medical Emergencies in the Dental Office. Ed.5 Mosby Inc.2000! Debralee McKelvey Nelson. Saunders Review of Dental Hygiene. Ed.1 W.B. Saunders Company. 2000! Ivor G. Chestnutt, John Gibson. Churchill s Pocketbook of Clinical Dentistry. Ed.2 Churchill Livingstone. 2002! James W. Little et al. Dental Management of the Medically Compromised Patient. Ed. 6 Mosby Inc. 2002 Mahmoud H. Al-Johani, BDS, www.saudident.com 9