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Friday, 1 February 2013

Medical Emergency In Dental Clinic


Medical emergencies can happen in the dental office, possibly threatening a patient’s life and hindering the delivery of dental care. Early recognition of medical emergencies begins at the first sign of symptoms


Types of Emergencies 
Altered Consciousness

Vasodepressor Syncope (common faint):

  • Recognition: Patient does not respond to "shake and shout" technique.
  • Position: Supine with feet elevated slightly.  
  • Airway: head tilt-chin lift must be done.
  • Breathing: "Look, listen and feel" indicates that satisfactory respiration is present. 
  • Circulation: Palpation of carotid pulse. Pulse is present, rate of 25/minute.  
  • Definitive management: Oxygen, aromatic ammonia (if available). Aromatic ammonia vaporole is crushed in fingers and held beneath nose of victim. 
Hypoglycemia:
  • Recognition of hypoglycemia: Diabetic patient appears cold, sweaty, shay and mentally disoriented.
  • Position: Comfortable, most likely somewhat elevated. 
  • Airway: OK, not necessary to maintain. Breathing: OK, not necessary to ventilate. 
  • Circulation: Palpation of carotid pulse, pulse is present.
  • Definitive management: In conscious patient-10-20 grms glucose orally, eg: orange juice,4x glucose tablets or gel. Unconscious patient-Glucagon 1mg(IM),50 %dextrose(IV)
Convulsions:
Tonic- clonic seizures:
  • Recognition: Sudden collapse & loss of consciousness.
    •  Tonic phase (approx 30 secs):Rigidity & cyanosis
    • Clonic phase (few mins):Jerking movements of limbs,  tongue may be bitten; frothing at  mouth & incontinence may occur
  • Position: Supine with feet elevated slightly on dental chair, supine on left side if on floor. 
  • Airway: head tilt-chin lift must be done. Head should be turned to a side to prevent the tongue from falling back & obstruct airways. 
  • Breathing: "Look, listen and feel" indicates that satisfactory respiration is present. 
  • Circulation: Palpation of carotid pulse. 
  • Definitive management: Activate EMS immediately. Protect the victim's arms and legs from injury during the seizure by gently holding them and allowing movement within limits. Do not restrain the patient from moving at all, as this increases the likelihood of injury. Do not attempt to place anything into the mouth of the seizing victim. Seizures usually terminate spontaneously within two to five minutes. 
    • If seizure continues( status epilepticus)- IV diazepam 10 mg
Respiratory Distress:
Asthma :
Position of asthmatic patient
  • Recognition: Breathlessness & expiratory wheeze. 
  • Position:  Comfortable, most likely upright. 
  • Airway: OK, not necessary to maintain. 
  • Breathing: OK, wheezing usually present, but it is not necessary to ventilate. 
  • Circulation: Palpation of carotid pulse is present
  • Definitive management: Hand patient bronchodilator and have her self-administer her usual dose (usually one to two inhalations/dose). 
    • If after three doses of the bronchodilator there is no improvement, take additional measures
    • Administer oxygen
    • Call for medical assistance
    • Intramuscular injections of 0.3-0.5 ml of epinephrine 1:1000 concentration for an adult, 1:2000 concentration for a child.
Allergic reaction during dental treatment:
Drug allergy

  • Recognition: Allergy is recognized by the presence of a skin reaction consisting of urticaria, pruritis and erythema (itching, hives and rash). More severe allergic reactions may involve stimulation of exocrine glands, producing watery eyes, a running nose and gastrointestinal upset (cramping)
  • Position:  Comfortable, as patient is conscious. 
  • Airway: can maintain..if not head tilt-chin lift
  • Breathing: "Look, listen and feel" indicates that satisfactory respiration is present.  
  • Circulation:  monitor blood pressure 
  • Definitive management: Administer histamine-blocker (diphenhydramine 50mg) IM.
Anaphylaxis

  • Recognition: same as drug allergy with respiratory involvement consisting of bronchospasm, noted by difficulty breathing and wheezing; and/or cardiovascular involvement, manifested by vasodialtion which, if severe, may lead to hypotension and the loss of consciousness. 
  • Position:  Comfortable, as patient is conscious. 
  • Airway: can maintain..if not head tilt-chin lift
  • Breathing: "Look, listen and feel" indicates that satisfactory respiration is present.  
  • Circulation:  monitor blood pressure, palpate carotid artery 
  • Definitive management: 0.3 mg of 1:1,000 epinephrine IM, repeat every 5 mins. till hypotention becomes normal.
  • Administer histamine-blocker (diphenhydramine 50mg) IM
  • Aminophyline IV
  • Hydrocortisone 100mg IV 

Chest Pain
Angina Pectoris 
  • Recognition: Patient, with a known history of angina, is familiar with clinical signs and symptoms. Frequently described as a tightness, heaviness, constricting or a burning sensation, in the substernal region. 
  • Position: Comfortable, most likely somewhat elevated. 
  • Airway: can maintain
  • Breathing: can maintain 
  • Circulation: Patient is consicous. Palpation of carotid pulse, pulse is present. 
  • Definitive management: Administer nitroglycerin sublingually (may repeat in 3-5 minute intervals 3 times). Monitor blood pressure after each dose; do not repeat if systolic BP drops below 100.  Average drop in BP is 11-16 mm Hg after one dose.  Patient should be sitting or supine when Nitroglycerine is administered.
NOTE: If exposed to oxygen/light it is only effective for 12 weeks.  
Most cases- 6 month shelf life. 
  • When using it should produce a bitter taste
  • The translingual nitro spray has a longer shelf life. (2 years)
  • If your patient has taken Viagra within the past twenty four hours, you must never administer nitroglycerine. 
  • Why? The patient's blood pressure can fall to dangerously low levels. If their systolic blood pressure drops to below 100, the patient could faint or lose consciousness. 
  • The treatment would be to place the victim into the Tredelenburg position, administer oxygen, go to your A,B,C, D's, and give aspirin if chest pain develops.
If no improvement after 15 minutes, treat as acute myocardial infarction.

Acute myocardial infraction
  • Recognition: Recognition of myocardial infarction: chest "pain" occurring in the absence of a previous history should be considered as serious, potentially myocardial infarction. In addition, if a patient with an anginal history ever states that his or her discomfort is worse than usual, or if two doses of nitroglycerin fail to alleviate the discomfort, or if the "anginal" pain is relieved by nitroglycerin administration but returns 
  • Position: Comfortable, upright 
  • Airway: can maintain
  • Breathing: can maintain 
  • Circulation: Palpation of carotid pulse, pulse is present, but may be irregular. 
  • Definitive management: Activate EMS immediately
  • Asprin tablet 325 mg. ask the patient to chew then swallow.
  • Nitroglycerine
  • Nitrous oxide with oxygen
Cardiac arrest 
Recognition: Sudden unconsciousness, no breathing, no pulse.
perform CPR
NOTE  :for CPR the sequence of ABC changes to CAB
CPR steps
1. Begin EMS
 Take charge
 Call out for help
 Make the area safe; wear gloves
2. Assess responsiveness
 Shout and gently tap/shake
3. Phone your emergency response number
 If patient is a child, phone your emergency response number after giving
5 sets of 30 compressions and 2 breaths
4. Open airway
 Tilt the head back, lift chin
 If patient is not breathing, give 2 breaths that make the chest rise.
5. Check breathing
 Look, listen and feel for no more than 10 seconds
 If patient is not breathing, continue with next steps
6. Give 2 slow breaths
 Use face shield/mask
 Check for chest movement
7. Begin chest compressions
 Landmark for hand position
 Give chest 30 compressions / 2 breaths at a rate of 100/minute
8. Continue until medical help arrives

Medical emergencies may be rare but they are challenging occurrences in the dental clinic, tasking the knowledge, skills and materials available to the practice. Adequate staff training and availability of appropriate drugs and equipment are essential in the management of emergencies that may arise in the dental clinic.


 



 

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