Medical Emergency In Dentistry
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Department of Pedodontic & Preventive Dentistry
Medical Emergency used in dentistry
Guided by –
Presented by -
Dr. RANDHEER Modi
Abdul Wahab
Content
Introduction Common medical emergency in dental office Emergency kit Various drugs Refrences
INTRODUCTION Emergency is a life threatening situation frequently occurring in dental office. Many factors increase such incidence, that is:(1) Older person. (2) Therapeutic advance in medical profession. (3) Long dental appointment. (4) Increase use & administration of drugs. In dental office, these situations are stress related or involve preexisting
Common medical emergencies in dental office – 1. Unconsciousness – Vasodepressor syncope. Orthostatic hypotension. Acute adrenal insufficiency.
2. Respiratory distress –
Airway obstruction Hyperventilation. Asthma. Heart failure and acute pulmonary edema .
3. Altered consciousness Diabetes mellitus , hyperglycemia and hypoglycemia. Thyroid gland dysfunction . Cerebrovascular accident
4. Seizures 5. drug related emergencies – Drug overdose . Allergy.
6.chest pain –
Angina pectoris. Acute MI .
7. Sudden cardiac arrest .
Steps to prepare the dental office for emergency
Train all office personnel in emergency procedures before an emergency occurs. Post the contact no. of the closer physician , emergency services and ambulance. Select the items including drugs and the devices for the emergency in the dental office and should check them after every 3 months.
Methods to minimizing emergencies in the dental office
Take complete case history including past medical, dental ,anesthetic experience and medication. Observe the patients stature , built , gait , color , age , respiration . Observe and record the amount of anxiety , use active listening to determine hidden nervousness . Record blood pressure and pulse. Perform any necessary lab investigations. Request medical consultant as needed.
Things to remember
Drugs are not necessary for the management of most emergencies . Primary management of all emergencies is basic life support. When in doubt , never medicates. Ideal route of emergency drugs administration will be IV , as the onset is rapid and the effect is most reliable using this route. Emergency drugs may be administrated IM into various sites like thigh , the upper outer quadrant of the gluteal region and the deltoid region. Remember in the absence of effective
Emergency kit
Module one – basic emergency kit ( critical drugs and equipment). Module two – non critical drugs and equipment. Module three – ACLS drugs. Module four – antidotal drugs.
Module one
1. Primary drugs
Injectable - Antiallergic -Histamine blockers Bronchodilator
Antihypoglycemic
Noninjectable Oxygen Vasodilator
1.Epinephrine Action:- rapid onset of action, potent action as bronchial smooth muscle dilator , antihistaminic properties and vasopressor properties , increase in heart rate ,systolic blood pressure and cardiac output, decrease in systolic blood pressure. Side effects – cardiac arrhythmias , short duration of action. Pregnancy ,as it reduces placental blood flow and may lead to premature labor
. Indications – cardiac arrest , anaphylaxis , acute asthmatic attack
Availability – for IV 1:1000 conc. And 1:10,000 for IM ---- ADRENLINE inj. Dentist may give into the frenulum under the tongue. Dose – 0.3 – 0.5 mg of solution.
2.chlorpheniramine , diphenhydramine Action :- prevent histamine access – receptor in cell----response in blocked Indications – Delayed onset allergic reactions , definitive management of acute allergic reaction Side effects :-CNS depression, decrease in blood pressure, thickening of bronchial secretion Contraindications – acute asthmatic
Availability – chlorpheniramine – 10 mg /ml IV, diphenhydramine – 10 mg / ml and phenramine maleate ( Avil ) – amp 1-2 ml IM .
Noninjectable drugs ; 1. Oxygen – important drug. Supplied as Compressed gas cylinders ( E cylinders),provide O2 for 30 min. Indication :- in respiratory distress. Patient with COPD should be given with caution because apnea may result
2. nitroglycerine or amyl nitrate. Indications - acute anginal attack or acute hypertensive episodes Contraindications – in hypotensive patient . Action – when it place sublingually , it acts in 1-2 min. Availability – tablet 0.1 , 0.3 , 0.6 mg. nitroglycerine spray – 0.4 mg /dose and amyl nitrate vaporous or – 0.3 ml. As NITROCONTIN, NITROCIN,NITROLINGUAL…..
3. Albuterol/ Metaproterenol:Action :- Bronchial smooth muscle relaxant property Indication;- Acute asthmatic attack and allergic reaction with bronchospsm Availability:- Albuterol inhaler (VENTOLIN, PROVENTIL) Metaproterenol INHALER ( ALUPENT)
4.Antihypoglycemic – Drug of choice – 50% dextrose solution . Indications – IV dextrose is used to manage hypoglycemic episode when diabetic patient is unconscious and cant swallow. Administration – can be given IM or IV.
5. Aspirin :Action :- antiplatelet activity--- stop production of production of proaggregatory throboxane A2 and acylation of platelet cyclooxygenase Indication ;- Myocardial infarction or unstable angina Availability :- ASALITE, ASPENT, SPRIN… 50-100mg /day
Module two A). Secondary Injectable drugs 2. Midazolam :action :- anticonvulsant activity Indication :- Prolonged seizures, Local anesthetic induced seizures, hyperventilation ,thyroid storm Availability:- MIDAZ, MIDOSED, FULSED.. 5mg/ml in 1,2,35,10 ml vial
2. Morphine sulphate Indications – acute MI .also given in CHF and intense prolonged and anxiety. Side effects – CNS and respiratory depressant Availability – morphine sulfate 10 mg / ml
3. Methoxamine Action – i adrenergic agonist with almost exclusively alpha – adrenergic agonist , produces mild increase in BP due to peripheral vasoconstriction.
Indications – treatment of acute adrenal insufficiency , Syncopal reactions , drug overdose reaction or allergy. Contra indication :-high blood pressure or ventricular tachycardia Availablity and dose – 10 mg /ml IV or IM as VASOXYSL
4. Antihypoglycemic:5. Hydrocorticosone sodium succinate . Indication – allergic reaction , anaphylaxis and adrenal crisis. Action – slow onset of action so epinephrine is still the drug of choice Availability :- 50mg/ml 2 ml vial as SOLU- CORTEF
6. Esmolol/ Propanolol ; Action – beta adrenergic blocker Indication:- Hypertension, angina pectoris, cardiac arrhythmia, post myocardial tachycardia. Contraindication ;- COPD, Partial or cmplete heart block. Availability :-2.5 mg in 10 ml ampule as ESOCARD, MINIBLOCK….
7. Atropine :Action/Indication:- in bradyarrythmias and asystole that is refractory to epinephrine. Side effects ;- large doses > 2 mg ---overdose ----hot, dry skin, headache, blurred vision, dry mouth and throat, disorientation, hallucination Availability:- .5 mg/ml in 1ml vial
B. Secondary Injectable drugs :1. Aromatic ammonia spirit – it is used to treat syncope . Action – it acts by irritating the membrane of the upper respiratory tract ,resulting in stimulation of respiration and BP. Contraindication – in asthma or COPD may precipitate bronchspasm Availability - in silver – grey vaporole 0.3 ml .
2. Nifidepine:Indication:- Hypertension, acute anginal pain Side effects :- Excessive hypotension Availability:- 10mg , 20 mg capsules as PROCARDIA
Module Three 1. oxygen 2.Lidocaine: Action /indication.:- Local anesthetic and antiarrhythmic action , used in ventricular Tachyarrhythmias 1mg/kg body wt.slow iv bolus over 5-10 min. Contraindication:- Hypersensitivity, Bradycardia, Serious conduction disturbance.
Availability:- GESICARD anhydrous XYLOCARD 3.Atropine:Action/Indication:- in bradyarrythmias and asystole that is refractory to epinephrine.
4. Dopamine :Action :- stimulates alpha and beta adrenergic receptors , release of norepinephrine Indication :-Hemodynamically significant hypotension in absence of hypovolemia. Side effects :- Increase heart rate, ventricular dysrhythmias, nausea , vomiting. Availability:- as INTROPIN 200mg, 400mg, 800mg in 5ml ampules
5. Morphine :- for ischemic chest pain. 6. Verapamil :Action :- Ca blockade --- effect on smooth muscle of coronaries ---increase myocardial blood flow.----decrease in peripheral resistance. Indication:-Paroxysmal supraventricular tachycardia Side effects :- transient decrease in blood pressure, nausea, constipation, headache, flushing.
Avai lability:- as CALAPTIN, VASOPTEN, VERAMIL
Module four Antidotal drugs :2. Naloxane Action:-Reverses all action of opoids…. Competitive at receptors. Indication :- Antagonizes opiod action like respiratory depression, sedation . Availability :- .4-2mg/ml in 1ml ampule IV ,IM or SC every 2-3 min.
Contraindication:- Hypersensitivity Alternative drug :- Nalbuphine. Side effects :Nausea, vomiting, hypertension.
2.Flumazenil: Action/ Indication :- reverses excessive sedation caused by benzodiazepine Side effects :- rebound anxiety Availability:- .1 mg/ml in 5ml and 10ml multidose vial as ROMAZICON
3.Physostigmine:Action/ Indication:- reversible cholinsterase ----crosses blood brain barrier--reverses emergence delirium. Side effects:-Increased salivation -bradycardiaemesis -involuntary urination and defecation Availability:- 1 mg/ml in 2ml ampule as ANTILIRIUM
4.Procaine :Action :- Local anesthetic and vasodilatation. Indication :- to manage vasospasm and compromised circulation by intrarterial inj. or by irritating drug Availability:- 1% sol. In 2ml and 6ml ampules as NOVACAIN
CONCLUSION
Proper management of a patient in almost all emergency situation does not require drug administration. First & foremost in the management oe emergency situation are steps of basic life support.
References
Medical emergencies in dental office – malamed Emedice.com Google.com
Medical Emergency used in dentistry
Guided by –
Presented by -
Dr. RANDHEER Modi
Abdul Wahab
Content
Introduction Common medical emergency in dental office Emergency kit Various drugs Refrences
INTRODUCTION Emergency is a life threatening situation frequently occurring in dental office. Many factors increase such incidence, that is:(1) Older person. (2) Therapeutic advance in medical profession. (3) Long dental appointment. (4) Increase use & administration of drugs. In dental office, these situations are stress related or involve preexisting
Common medical emergencies in dental office – 1. Unconsciousness – Vasodepressor syncope. Orthostatic hypotension. Acute adrenal insufficiency.
2. Respiratory distress –
Airway obstruction Hyperventilation. Asthma. Heart failure and acute pulmonary edema .
3. Altered consciousness Diabetes mellitus , hyperglycemia and hypoglycemia. Thyroid gland dysfunction . Cerebrovascular accident
4. Seizures 5. drug related emergencies – Drug overdose . Allergy.
6.chest pain –
Angina pectoris. Acute MI .
7. Sudden cardiac arrest .
Steps to prepare the dental office for emergency
Train all office personnel in emergency procedures before an emergency occurs. Post the contact no. of the closer physician , emergency services and ambulance. Select the items including drugs and the devices for the emergency in the dental office and should check them after every 3 months.
Methods to minimizing emergencies in the dental office
Take complete case history including past medical, dental ,anesthetic experience and medication. Observe the patients stature , built , gait , color , age , respiration . Observe and record the amount of anxiety , use active listening to determine hidden nervousness . Record blood pressure and pulse. Perform any necessary lab investigations. Request medical consultant as needed.
Things to remember
Drugs are not necessary for the management of most emergencies . Primary management of all emergencies is basic life support. When in doubt , never medicates. Ideal route of emergency drugs administration will be IV , as the onset is rapid and the effect is most reliable using this route. Emergency drugs may be administrated IM into various sites like thigh , the upper outer quadrant of the gluteal region and the deltoid region. Remember in the absence of effective
Emergency kit
Module one – basic emergency kit ( critical drugs and equipment). Module two – non critical drugs and equipment. Module three – ACLS drugs. Module four – antidotal drugs.
Module one
1. Primary drugs
Injectable - Antiallergic -Histamine blockers Bronchodilator
Antihypoglycemic
Noninjectable Oxygen Vasodilator
1.Epinephrine Action:- rapid onset of action, potent action as bronchial smooth muscle dilator , antihistaminic properties and vasopressor properties , increase in heart rate ,systolic blood pressure and cardiac output, decrease in systolic blood pressure. Side effects – cardiac arrhythmias , short duration of action. Pregnancy ,as it reduces placental blood flow and may lead to premature labor
. Indications – cardiac arrest , anaphylaxis , acute asthmatic attack
Availability – for IV 1:1000 conc. And 1:10,000 for IM ---- ADRENLINE inj. Dentist may give into the frenulum under the tongue. Dose – 0.3 – 0.5 mg of solution.
2.chlorpheniramine , diphenhydramine Action :- prevent histamine access – receptor in cell----response in blocked Indications – Delayed onset allergic reactions , definitive management of acute allergic reaction Side effects :-CNS depression, decrease in blood pressure, thickening of bronchial secretion Contraindications – acute asthmatic
Availability – chlorpheniramine – 10 mg /ml IV, diphenhydramine – 10 mg / ml and phenramine maleate ( Avil ) – amp 1-2 ml IM .
Noninjectable drugs ; 1. Oxygen – important drug. Supplied as Compressed gas cylinders ( E cylinders),provide O2 for 30 min. Indication :- in respiratory distress. Patient with COPD should be given with caution because apnea may result
2. nitroglycerine or amyl nitrate. Indications - acute anginal attack or acute hypertensive episodes Contraindications – in hypotensive patient . Action – when it place sublingually , it acts in 1-2 min. Availability – tablet 0.1 , 0.3 , 0.6 mg. nitroglycerine spray – 0.4 mg /dose and amyl nitrate vaporous or – 0.3 ml. As NITROCONTIN, NITROCIN,NITROLINGUAL…..
3. Albuterol/ Metaproterenol:Action :- Bronchial smooth muscle relaxant property Indication;- Acute asthmatic attack and allergic reaction with bronchospsm Availability:- Albuterol inhaler (VENTOLIN, PROVENTIL) Metaproterenol INHALER ( ALUPENT)
4.Antihypoglycemic – Drug of choice – 50% dextrose solution . Indications – IV dextrose is used to manage hypoglycemic episode when diabetic patient is unconscious and cant swallow. Administration – can be given IM or IV.
5. Aspirin :Action :- antiplatelet activity--- stop production of production of proaggregatory throboxane A2 and acylation of platelet cyclooxygenase Indication ;- Myocardial infarction or unstable angina Availability :- ASALITE, ASPENT, SPRIN… 50-100mg /day
Module two A). Secondary Injectable drugs 2. Midazolam :action :- anticonvulsant activity Indication :- Prolonged seizures, Local anesthetic induced seizures, hyperventilation ,thyroid storm Availability:- MIDAZ, MIDOSED, FULSED.. 5mg/ml in 1,2,35,10 ml vial
2. Morphine sulphate Indications – acute MI .also given in CHF and intense prolonged and anxiety. Side effects – CNS and respiratory depressant Availability – morphine sulfate 10 mg / ml
3. Methoxamine Action – i adrenergic agonist with almost exclusively alpha – adrenergic agonist , produces mild increase in BP due to peripheral vasoconstriction.
Indications – treatment of acute adrenal insufficiency , Syncopal reactions , drug overdose reaction or allergy. Contra indication :-high blood pressure or ventricular tachycardia Availablity and dose – 10 mg /ml IV or IM as VASOXYSL
4. Antihypoglycemic:5. Hydrocorticosone sodium succinate . Indication – allergic reaction , anaphylaxis and adrenal crisis. Action – slow onset of action so epinephrine is still the drug of choice Availability :- 50mg/ml 2 ml vial as SOLU- CORTEF
6. Esmolol/ Propanolol ; Action – beta adrenergic blocker Indication:- Hypertension, angina pectoris, cardiac arrhythmia, post myocardial tachycardia. Contraindication ;- COPD, Partial or cmplete heart block. Availability :-2.5 mg in 10 ml ampule as ESOCARD, MINIBLOCK….
7. Atropine :Action/Indication:- in bradyarrythmias and asystole that is refractory to epinephrine. Side effects ;- large doses > 2 mg ---overdose ----hot, dry skin, headache, blurred vision, dry mouth and throat, disorientation, hallucination Availability:- .5 mg/ml in 1ml vial
B. Secondary Injectable drugs :1. Aromatic ammonia spirit – it is used to treat syncope . Action – it acts by irritating the membrane of the upper respiratory tract ,resulting in stimulation of respiration and BP. Contraindication – in asthma or COPD may precipitate bronchspasm Availability - in silver – grey vaporole 0.3 ml .
2. Nifidepine:Indication:- Hypertension, acute anginal pain Side effects :- Excessive hypotension Availability:- 10mg , 20 mg capsules as PROCARDIA
Module Three 1. oxygen 2.Lidocaine: Action /indication.:- Local anesthetic and antiarrhythmic action , used in ventricular Tachyarrhythmias 1mg/kg body wt.slow iv bolus over 5-10 min. Contraindication:- Hypersensitivity, Bradycardia, Serious conduction disturbance.
Availability:- GESICARD anhydrous XYLOCARD 3.Atropine:Action/Indication:- in bradyarrythmias and asystole that is refractory to epinephrine.
4. Dopamine :Action :- stimulates alpha and beta adrenergic receptors , release of norepinephrine Indication :-Hemodynamically significant hypotension in absence of hypovolemia. Side effects :- Increase heart rate, ventricular dysrhythmias, nausea , vomiting. Availability:- as INTROPIN 200mg, 400mg, 800mg in 5ml ampules
5. Morphine :- for ischemic chest pain. 6. Verapamil :Action :- Ca blockade --- effect on smooth muscle of coronaries ---increase myocardial blood flow.----decrease in peripheral resistance. Indication:-Paroxysmal supraventricular tachycardia Side effects :- transient decrease in blood pressure, nausea, constipation, headache, flushing.
Avai lability:- as CALAPTIN, VASOPTEN, VERAMIL
Module four Antidotal drugs :2. Naloxane Action:-Reverses all action of opoids…. Competitive at receptors. Indication :- Antagonizes opiod action like respiratory depression, sedation . Availability :- .4-2mg/ml in 1ml ampule IV ,IM or SC every 2-3 min.
Contraindication:- Hypersensitivity Alternative drug :- Nalbuphine. Side effects :Nausea, vomiting, hypertension.
2.Flumazenil: Action/ Indication :- reverses excessive sedation caused by benzodiazepine Side effects :- rebound anxiety Availability:- .1 mg/ml in 5ml and 10ml multidose vial as ROMAZICON
3.Physostigmine:Action/ Indication:- reversible cholinsterase ----crosses blood brain barrier--reverses emergence delirium. Side effects:-Increased salivation -bradycardiaemesis -involuntary urination and defecation Availability:- 1 mg/ml in 2ml ampule as ANTILIRIUM
4.Procaine :Action :- Local anesthetic and vasodilatation. Indication :- to manage vasospasm and compromised circulation by intrarterial inj. or by irritating drug Availability:- 1% sol. In 2ml and 6ml ampules as NOVACAIN
CONCLUSION
Proper management of a patient in almost all emergency situation does not require drug administration. First & foremost in the management oe emergency situation are steps of basic life support.
References
Medical emergencies in dental office – malamed Emedice.com Google.com
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