Medical Emergencies

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(Medical Emergencies)

• (Prevention)
• (Management)

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Patient at Risk Dentist at Risk
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Introduction

• Emergencies in dental practice can occur to any
  person any time.
• How to manage it is the most difficult thing at
  time occurred.

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Introduction

• The majority emergency is syncope.

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Introduction
Others

• anaphylactic reaction
• cerebrovascular accident
• adrenal insufficiency
• thyroid storm
• etc

• allergic reaction
• angina pectoris
• postural hypotension
• seizures
• asthmatic attack
• hyperventilation
• hypoglycemia

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Consciousness

• Composition of consciousness
• Brain
• O2
• Glucose
• Effective hemodynamic

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Fact of human brain

• Uses O2 approx. 20 of total O2
• Uses glucose approx. 65 of total glucose
• Uses approx. 20 of total circulation/min (750
  ml.min.)

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Consciousness

• Balance mechanism of
• Hemodynamic
• Respiration
• Metabolism
• Neurologic

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Unconsciousness

• Caused from impair ..
• Hemodynamic
• Respiration
• Metabolism
• Neurologic

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How to avoid these complications

• Prevention is the best
• Good history taking
• Good preoperative preparation
• Good operative controls

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Possible causes of unconsciousness in the dental
office

• Vasodepressor syncope
• Drug administration /ingestion
• Orthostatic hypotension
• Epilepsy
• Hypoglycemic reaction
• Acute adrenal insufficiency

• Acute allergic reaction
• Acute myocardial infarction
• Cerebrovascular accident
• Hyperglycemic reaction
• Hyperventilation syndrome

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Alteration of consciousness

• Cerebrovascular accident (CVA)
• Seizures
• Hypoglycemia / Hyperglycemia
• Adrenal insufficiency
• Thyroid storm
• Hyperventilation
• Drug overdose

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Unconsciousness

• Syncope is the most common occurred.

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Factors influence

• Stress and anxiety
• Health status
• Drugs

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How syncope occur

• In normal circulation compensation mechanism
  play role in correction of deficiency O2 supply
  to the brain.

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How syncope occur

• In syncope circulation compensation mechanism
  fail to increase O2 need from the brain

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Signs for syncope

• Early
• Feeling of warmth
• Loss of color pale or ashengray skin tone
• Heavy perspiration
• Complaints of feeling bad of faint
• Nausea
• Blood pressure approximately baseline
• Rapid heart rate

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Signs for syncope

• Late
• Pupillary dilation
• Yawning
• Hyperpnea
• Cold hands and feet
• Hypotension
• Bradycardia
• Dizziness
• Loss of consciousness

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Critical consideration

• Timing of detection and correction
• Maintain O2 level to the brain Airway
  Breathing Circulation (ABC - Basic life support)

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Orthostatic hypotension

• Failure of the baroreceptor reflex
• Loss of compensate mechanism
• Reflex bradycardia
• Loss of consciousness

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Drugs producing orthostatic hypotension
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Unconsciousness

• Assessment Check for Breathing
• Look the chest to rise and fall
• Listen for air escaping during exhalation
• Feel for the flow of air

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Unconsciousness no response to stimuli
P - position SUPINE
Call for help EMS activation
A B Airway (head tilt - chin lift) Artificial
Assisted Breathing (if no self respiration)
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C check circulation
Carotid pulse absent
Carotid pulse present
Check medical history Vital signs
Activate EMS
Recovery
unrecovery
Initiate CPR Immediate transportation
Orthostatic hypotension
Vasodepressor syncope
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Sequence of BCLS

• Assessment
• EMS Activation
• ABCs of CPR
• D of Defibrillation

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ABCs of CPR

• Airway
• Breathing
• Circulation

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Airway

• Position the victim
• Rescuer position
• Open the Airway
• Head Tilt - Chin Lift Maneuver
• Jaw Thrust Maneuver
• Recommendations for Opening the Airway

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Classification of causes of unconsciousness by
mechanism

• Mechanism
• Inadequate delivery of blood or oxygen to the
  brain

• Clinical example
• Acute adrenal insufficiency
• Orthostatic hypotension
• Vasodepressor syncope

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Classification of causes of unconsciousness by
mechanism

• Mechanism
• Systemic or local metabolic deficiencies

• Clinical example
• Acute allergic reaction
• Drug ingestion and adminstration
• Nitrites and nitrates
• Diuretics
• Sedatives-narcotics
• Local anesthetics
• Hyperglycemia
• Hyperventilation
• Hypoglycemia

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Classification of causes of unconsciousness by
mechanism

• Mechanism
• Direct or reflex effects on nervous system
• Psychic mechanisms

• Clinical example
• Cerebrovascular accident
• Convulsive episodes
• Emotional disturbances
• Hyperventilation
• Vasodepressor syncope

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CHEST PAIN
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Causes of chest pain

• Cardiac related
• Angina pectoris
• Myocardial infarction

• Non-cardiac related
• Muscle strain
• Pericarditis
• Esophagitis
• Hiatal hernia
• Pulmonary embolism
• Dissecting aortic aneurysm
• Acute indigestion
• Intestinal gas

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Chest pain is one of the major clinical clues to
the presence of significant heart disease.
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Definition of Terms

• Atherosclerosis is a special type of
  thickening and hardening of medium - sized and
  large arteries because of deposits of a fatty
  substance.
• is an ongoing process
• is a reactive biologic response of arteries to
  the forces being generated by the flow of blood.

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• Atherosclerosis is the major factor underlying
  all forms cardiovascular disease.

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Pathology of atherosclerosis
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Normal structure
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Development of atherosclerosis

• Proliferative change

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Development of atherosclerosis

• Lipid deposition

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The development of ACS

• Early plaque formation
• Significant plaque formation
• Plaque rupture
• Thrombus

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Coronary artery disease is the presence of
atherosclerosis in the coronary arteries.

• Angina pectoris
• Myocardial infarction

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Angina is a transient discomfort (usually less
than 15 minutes) due to a temporary lack of
adequate blood supply to the heart muscle.
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Myocardial infarction is defined as death of
heart muscle (myocardium) as the result of
prolonged inadequate blood flow and oxygen
delivery.
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Acute coronary syndromes encompasses symptomatic
condition resulting in an inadequate blood supply
to the heart including unstable angina and AMI.
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AMI (heart attack) is defined as death of heart
tissue due to blockage of a coronary artery
caused by atherosclerosis and thrombus formation.
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Unstable angina

• Angina that is continuing prolonged or occurring
  at rest.
• Represents a syndrome that lies between angina
  pectoris and AMI.

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Unstable
Angina pectoris --------------gt AMI
Angina
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Risk factors Heart attack

• Risk factors that cannot be changed
• Age
• Heredity
• Gender
• Race

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Risk factors that can be changed

• Cigarette smoking
• High blood pressure
• High blood cholesterol level

• Physical inactivity
• Diabetes
• Obesity
• Excessive stress

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Diagnosis

• Electrocardiogram (EKG)
• Exercise stress test
• Echocardiogram
• Coronary angiography

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Treatment

• 1. Coronary artery bypass graft surgery (CABGS)
• 2. Medical therapy
• 3. Percutaneous Transluminal Coronary Angioplasty
  (PTCA) Percutaneous Coronary Intervention
  (PCI)

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Drugs and bleeding in patient with CAD

• Aspirin
• Plavix
• Ticlid
• Coumadin

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Dental Management
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Angina pectoris

• Potential problem related to dental care
• 1. Stress and anxiety related to dental visit may
  precipitate angina attack
• 2. Myocardial infarction
• 3. Sudden death

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Angina pectoris

• Prevention of complication
• 1. Detection of patient
• 2. Referral of patient for medical evaluation and
  treatment

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• Prevention of complication
• 3. Known case with medical treatment for angina
• Stress reduction protocol
• Premedication
• Open and honest communication
• Morning appointments
• Short appointments
• Nitrous oxide - oxygen
• Avoid excessive amounts of epinephrine

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Emergency action plan for a person with signals
of heart attack
Unknown case of CAD Recognize the signals of a
heart attack Stop activity and sit or lie
down Wait about 5 minutes to see if the symptom
go away. If the pain persists
Known case of CAD Recognize the signals of heart
attack Stop activity and sit or lie down Take 1
nitroglycerin tablet at a time at 3 - to 5
minutes intervals to maximum total dose of 3
tablets. If pain persists.
Transport patient to hospital
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Myocardial infarction
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Potential problem related to dental care

• 1. Cardiac arrest
• 2. Myocardial infarction
• 3. Angina pectoris
• 4. Congestive heart failure
• 5. Bleeding tendency secondary to anticoagulant

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Prevention of complication

• 1. No routine dental care until at least 6 months
  after infarction
• 2. Medical consultation
• Current status
• Medication used

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• 3. Stress reduction protocol
• Premedication
• Open and honest communication
• Morning appointment
• Short appointment
• Nitrous oxide - oxygen
• 4. Avoid excessive amounts of epinephrine
• 5. Check PT (Anticoagulant medication)

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Management of Acute Myocardial Infarction

• Step 1. Diagnosis
• Administer nitroglycerin
• 2. Initiate BLS
• 3. Summon medical assistance
• 4. Administer oxygen and monitor vital signs
• 5. Relive pain
• Morphine
• Nitrous oxide - oxygen
• 6. Transport patient to hospital

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Case Study

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Consultations report
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Medical Problem List

• 1. Coronary artery disease double - vessel
• Status post PCI .. .. 46
• at present asymptomatic
• 2. DM controlled
• 3. HT controlled

• 4. Old CVA Left hemiparesis 5 yrs ago at
  present complete recovery
• 5. Mild renal insufficiency
• 6. Mild late onset asthma

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Current medication

• 1. Aspent gr. V 1 x 1 orally pc.
• 2. Plavix 1 x 1 orally pc.
• 3. Plendil 1 x 2 orally pc.
• 4. Minidiab 1 x 1 orally pc.
• 5. Bestatin 1 x 1 orally pc.
• 6. Singvalac 1 x 1 hs.

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DISCUSSION
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Good Luck