Hanaa Ajour & hebah ramadneh

Dr Fadi jarab

4/7/2013

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IMPORTANT CORRECTIONS FOR THE FIRST SCRIPT:

1) Page 3:
Line 14, it isnt osteoporosis; its ostioradionecrosis.

2) Page 4:
Line 3, (error) non-vertical, (correction) one-vertical

3) Page 4:
Line 21, the exception for the left hand is the lower left so, you should stand posterior to the patient in the left side. NOT anterior to him.

4) Page 10:
Line 4, we go more lingual because the bone buccaly is thicker. Not thinner.

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1st part of the lec: Last time we talked about forceps which is the instrument that we used for dental extraction .The other instrument that help us in extraction and sometimes they are the only instrument that we use for extraction they are Dental Elevator .

Dental Elevator: it is a single blade instrument (have only one blade not as
the forceps which have 2 blades) Connection between the blade and the handle called the shank. NOTE: The main difference between the elevators is related to the blade.

The elevator is usually used to:

Loosen difficult teeth prior to forceps delivery ( if you remember that we said the first step in dental extraction is gingival detachment then we do loosening by the elevator then we applied the forceps and do the extraction ) Deliver teeth that cannot be correctly gripped with forceps (don't have enough STR. In the coronal aspect ) Remove fractured roots
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There are different types of elevators:

1- copland elevator / copland chisel /straight elevator : is the main elevator & most common type that we used and is used in a way that you insert the blade between the tooth and the socket so it can cause a wedging effect _make a pressure to push the tooth out- so it has to be sharp . >>when using this elevator you have to have a fulcrum point (supporting point) so applied???? It in the socket then we do wedging after that we do a rotation so this will result in displacement of the tooth out of the socket.

2- Cryer elevator: the blade here is triangular , We have 2 crayers one for the right and one for the left (not as straight type) it is used for separation which mean sectioning the roots into mesial root alone and distal root alone after that I moving one root by somehow Warwick elevator or whaever then the other root we dont have an acess to it just from interproximal area and the pointed end of the triangular to be applied on the distal aspect of the mesial root and this result in displacement of tooth so if I want to extract the distal root I have to use the other one (the mesial aspect of the distal root). e.g. extraction of lower 6, separation of roost by
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sectioning into mesial and distal roots by bur, then we apply the Cryer on the distal aspect of the mesial root or mesial aspect of distal root.

3- Warwick elevator : We have 3 subtypes of it: straight, right and left -the blade is angle in away and no that pointed - It is used for extraction upper wisdom teeth, it has to be applied mesiobuccal to the tooth.

4- Apexo elevator : It has an angled and long blade bcz. It is used to remove fractured root tips in a situation that the root fractured in a level that can't griped by any instrument >>>>>> so it can enter the socket deep inside and remove the root fragment.
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Sequence of Extraction:

1- Maxillary teeth before mandibular teeth bcz. If we strated the mandibular teeth extraction and then we proceeded to extraction maxillary teeth, if we have any fragment or any foreign body will be insert to the socket of the lower teeth 2- Posterior teeth before anterior teeth bcz. If I started with ant. The blood will go back in post direction so I will not be able to continue the extraction NOTE: *** there are 2 teeth that should you have to take care of ! Which are (6 & 3) because of their roots? The 1st molar has divergent root and the canine is difficult bcz. It have long root. So if I want to extract the tooth from 8-1 I have to start post. (Except 6&3 first we remove their boundaries) So the sequence will be: 8>7>5>6>4>2>3>1
To facilitate the extraction of 6

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>>>>Can we do multiple extractions (right, left, upper, lower) in the same time? From scientific point there is no contra indication and sometimes its preferred into lower to extract teeth side by side, because of the numbness of the local anesthesia. But if you need to extract for example lower right 6 and lower left 6 in an emergency or the pt. asks you to do it is ok, or in patient who extract teeth under general anesthesia.

>>>> So there is no contraindication to extract the (right, left, upper, lower) in the same time. But generally we extract side by side which is recommended bcz. It will be easier for the pt.

Post extraction care: (very important thing you have to

memorize) Inspect the tooth : is it intact or detached Inspect the socket itself: anything remains or there is an amalgam or cyst and if any debridement I have to deprive & remove any foreign body in the socket. Squeeze the socket (if you remember when we are moving the tooth bucco-lingually direction and we make expansion for the socket this will make the constriction of prosthatic valve later on problematic) that's why after removing the tooth >>>>> by finger we squeeze the buccal and palatal bone together.

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* This squeezing will assist in hemostasis and better form of the new cells at healing. If there are blood vessels at the extraction line it will stop the bleeding. Pressure pack: the main idea to force pressure on the extraction site and this will closed the socket from any foreign body and it will assists in stopping the bleeding.

Post-operative instructions :
1) Pressure pack should not remove at least 30 minutes and we said for our pt. at least 1 hour. 2) Soft and cool diet: not hot at all bcz. The hot will induce bleeding 3) No hot beverages 4) Not to spit. The most important point of the healing is to form a blood clot in the EMPTY SOCKET. (If the pt. was always spitting >>every time the blood Clot is formed he removing these clot) 5) Not to smoke 6) Warm saline wash after 24 hours. 7) Prescription of analgesics (NSAIDs) , and there is no need for antibiotics
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Healing of Extraction wounds :

Formation of blood clot filling the socket >>> (most important step in healing) so if the blood clot is formed and still stable not slot the healing will go on. Organization of the clot Epithelialization of the surface >>>Within 1-2 months woven bone will start filling ,organizing clot and this woven bone will be reflect by trabecular bone & removing of the alveolus .

Delayed healing of extraction wound : Infection Pt. have a bleeding disorder-coagulation defect like (hemophilia A & B) so the clot itself is not form that's why the healing itself it delay. Formation of oro-antral fistula Pt. have a tumor (this is we should take seriously if we do an extraction to a pt. and there was no healing we should think about the tumor )
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 Radiotherapy, that affects the healing capacity of the bone, the bone is become (hypo-cellular, hypoxic, hypo-vascular) Immunodeficiency Scurvy, which is deficiency in Vitamin C.

Complications of teeth Extraction :

Local or systemic complications Intra complications

1) Fracture of the tooth. The management here is open extraction, you have to open a flat and remove the tooth which was fractured. (((there is an exception if the tooth fractured was a piece of root that it's root tip is less than 4 mm or less than 1/3 of the root and there is no infection surrounding the root, I can leave it with follow up))) 2) Fracture of the jaw. It usually happens while extracting an isolated lower 8 molar (there is a heavy load on this tooth so this will resulting in bone surrounding the tooth to be very dense >>> the extraction is very difficult & may be needed scattered more force but not force that resulted in fracture of the jaw .
The extraction does not need force, its a physical procedure.

3) Opening of the maxillary antrum. Maxillary sinuses have a relation with 4,5,6,7 & 8 The closest relationship being the palatal root of the maxillary first molar.
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Sometimes when we do the extraction we may result in a communication oro-antral communication-, Oro antral communication (communication between maxillary sinuses & oral cavity) If it is small then closed by suturing, given antibiotics and decongestants and ask the pt. to be followed up If it is large then closed by using flaps *** We should take care about the maxillary sinuses *** 4) Fracture of the maxillary tuberosity If we use heavy force the maxillary tuberosity will be fractured, if fractured it will result mainly in communication between the maxillary sinus and the oral cavity if the fractured piece is small I will removed it if its large and will result in the communication I have to return it back , post pone the extraction then do surgery and put wires sometimes between 7&8 As a complication of maxillary tuberosity fractured I have to check if there is a communication? >>>if the blood is coming out with air like bubbles (there is a communication because the maxillary sinuses will have air). So I have to return it back and fixing the upper 8 & 7 with wires, Post pone the extraction after the 2 weeks until the healing of bone happened. 5) Damage to soft tissue When we do an extraction there is a slippage of instruments so by careful control method I can avoid this complication of the instruments)
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6) Loss of the extracted tooth. The most important that I have to check if it is in the soft tissue around in the vestibules or floor of the mouth. If not I should check if it is dropped in the respiratory tract or GIT. If there was no coughing it means that it did not go to the lung and this is wrong this will not rule out the respiratory tract So I have to rule out the respiratory tract by taking two chest X-rays: (lateral one and anterior-posterior) If it is in the lung, its removed by bronchoscopy

If it is in the GIT, then no need for further treatment

NOTE:
We should know where the displaced tooth goes!! I should know where the displaced tooth or the remnant root is, because sometimes it may be displaced to the sinuses in case of maxillary teeth or the ID canal if its a mandibular one. You should remove the remnant root from the sinuses If we have bleeding. Do suction & know the source of bleeding, apply pressure with gauze. If the source from soft tissue (gingiva) then suture it, if it is from the bone (the socket itself) use bone wax, or check if it is a systematic factor. *** Most important thing to stop the bleeding is to put a pressure 7) Dry socket ( alveolar osteitis) The most common frequent painful complication of dental extraction This complication happened because of Because of failure of formation of the blood clot in the socket. So, complication starts after 2 days - its a characteristic sign for dry socket. Its most common to happen with wisdom tooth. Deep-seated, throbbing, sever aching pain
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 Mucous membrane is red and tender around the socket Most common disposing factors are smoking and spitting There will be no clot in the socket, and there will be whitish bone means that its dead. (healthy bone is yellowish in color) Its a rough area when touched with a probe. Treatment: keep the socket *clean (so you should remove the debris or any foreign body) and *open, you can put an analgesic gel (alveo-geal), so the patient feel relief of pain; we used alweo-geal because the pain here doesnt respond to any systemic analgesic.

2nd part of the lec:

The most common cause of loss consciousness on the dental chair is: Fainting: ( vaso-vagal syncope) It is the most common cause of sudden loss of consciousness, happen because of the stressful situation (Vaso-vagal syncope):
In the stressful situation the sympathetic system work which lead to vaso-constriction and hypertension, then the compensatory mechanism work (parasympathetic system), parasympathetic system work on the vagus nerve to make the situation normal but sometime its prominent so, the effect of the parasympathetic (vagus affect) is much more than sympathetic system and this lead to vasodilation of the vessels. ((((So, its called vaso-vagal: the effect of the vagus nerve on the vessels)))) The vasodilation effect lead to hypotension and decrease the blood flow to the brain which leads to loss of consciousness Sympathetic vasoconstriction hypertension parasympathetic vasodilation hypotension decrease blood flow to the brain loss of consciousness.

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Its most common happened with young adult especially female when they see the needle.

So its better to hold the needle down

Summary for fainting:

Vasovagal syncope Is the commonest cause of sudden loss of consciousness Predisposing factors : pain, anxiety, fatigue, fasting, relative hyperthermia (especially it comes from the chair light so you should turn it off when there is no need for it) Characteristic signs &symptoms : dizziness and nausea ,pale ,cold skin, slow thin thread pulse which rebounds to become rapid

Prevention: -Avoid predisposing factors -Treat patients in supine position unless contraindicated.
Management: -Terminate dental treatment -Lay the patient flat with slightly elevated legs to help the blood to go to the brain. -Loosen cloth (in presence of witness)
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-Monitor vital signs -Bradycardia, gives atropine100 micrograms IV -The patient should leave escorted

Acute chest pain: Ischemia of the myocardium; angina or MI this type is so much sever and sometime radiate to the left arm and shoulder. (retrosternal pain) Both exhibit severe retrosternal pain which is heavy ,crushing or band like in nature Classically preceded by effort ,excitement Pain may radiate to the arms , neck , jaw Angina is usually rapidly relieved by rest and by either sublingual glyceryl nitrate (0.5 mg), or GTN spray. If there is no relief that means its MI. (Failure of these methods to relieve pain and coexisting sweating, breathlessness, nausea, vomiting, loss of consciousness with a weak irregular pulse suggest an infarct) Management: *** In Office -place in upright position if possible to decrease the load on the cardiac muscle. -summon ambulance
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-administer analgesia (nitrous oxide/O2 mix) - Aspirin 150-300 mg PO ***In Hospital -Nurse upright -O2 -IV opioid analgesia (dimorphine) -ECG, U&Es -Some give thrombolytics Anaphylactic reaction Parentral penicillins are the commonest offenders Not all or no reaction ,grades are seen Generally, the reaction starts a few minutes after a parentral injection , not immediately as does a simple faint Symptoms: facial flushing, itching, numbness, cold extremities, nausea, possible abdominal pain Signs: wheezing, facial swelling, cold skin, thin thready pulse, possible loss of consciousness, extreme pallor which progress to cyanosis as respiratory failure develops

Management
-place patient supine with legs raised -O2 by mask Adrenaline (bronchodilator) 0.5 mg 1:1000 IM or SC and repeat after 5 min , If no improvement give: Up to 20 mg IM/slow IV chlorpheniramine Up to 500 mg IM/slow IV hydrocortisone Collapse In a Patient with a History of Corticosteroid Therapy

The use of corticosteroids may suppress the adrenal response to stress If patients have received steroids in the past year or are on steroids, cover any stressful procedure with 100 mg hydrocortisone IM 30 min(or doubling the oral dose) prior to elective stress
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In patients presenting acutely, profound sudden decrease in blood pressure, rapid thin pulse and pallor and loss of consciousness Management -Supine position -O2 -Up to 500 mg hydrocortisone IV (increase the dose of steroid) (If you dont give the patient steroid then he will develop hypotension and hypoglycemia) Adrenal crisis Fits The majority recover spontaneously Prevent patient from damaging himself May be precipitated in a known epileptic by starvation, lights, certain drugs as tricyclics and alcohol. They also may follow deep faint Many epileptics have a preceding aura followed by sudden loss of consciousness with a rigid extended appearance and generalized jerking movements Frequently, they are incontinent of urine and may bite their tongues There is also slow recovery with the patient feeling sleepy If the fitting repeated, the patient has entered status epilepticus which is emergency and requires urgent control

Management -in a simple fit, place patient in recovery position(if possible) -in status epilepticus IV lorazepam or diazepam and maintain airway (hospital based)

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 Hypoglycemia Most common diabetic emergency If emergency happened to diabetic patient ,consider that the patient has hypoglycemia not hyperglycemia Predisposing factors: missed meal, excess insulin, stress Diagnosis: disorientation, irritability, drowsiness, aggression (look as drunk) Treatment - If conscious: glucose orally in any form -If unconscious: protect airway, place in recovery position, Establish IV access and give up to 50 ml dextrose, or 1 mg glucagon IM Acute asthma An acute asthmatic attack may be induced in a patient predisposed to a bronchospasm by exposure to an allergen , infection, cold, exercise, or anxiety Characteristically, the patient will complain of a tight chest and breathlessness Management in dental office -keep the patient upright -administer salbutamol inhaler -give O2 -steroids *Be aware of the possibility of anaphylaxis mimicking acute asthma(anyway adrenaline is a bronchodialator)

Management in hospital -nurse patient upright -nebulized salbutamol 5 mg with O2

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- nebulized ipratropium 0.5 mg with O2 -up to 200 mg IV hydrocortisone -monitor ABGs, pulse oximetry

Inhaled foreign body Inhaled foreign body into the upper airways will stimulate the cough response , which may be sufficient to clear the obstruction If the obstruction is complete or there are signs of cyanosis in

1. Conscious patient: -back blows (up to 5) -Heimlich maneuver -combination of the above (5 back,5 abdomen)

2. Unconscious patient: -finger sweep -abdominal thrusts with Patient supine

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If all fail cricothyrotomy may preserve life if obstruction lies above this level

The ABCDE Approach:

A Airway B Breathing C Circulation D Disability AVPU E Exposure

Head Tilt/Chin Lift

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Cardio-Respiratory Arrest:
Most common cause ventricular fibrillation ADULT BASIC LIFE SUPPORT -check responsiveness (shake and shout and call for help) -create patent airway (chin lift or jaw thrust and manually clear the the oropharynx) -assess breathing (look,listen,feel), if person is breathing,put in recovery position if not, get help,give 2 effective breaths(up to 5 attempts. Then move to:

Adult Basic Life Support

Assess circulation(feel carotid pulse for 10 sec) If present: continue ventilation, and check for pulse every minute If not present: 100 chest compressions/min 15 compressions: 2 breaths Done by : hanaa ajour Hebahr r3d ramadneh

Great thanx for sawsan jawed

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Summary for this lecture

Done by: Muad S.Al-Zoubi
Part 1

Chisel: used to remove bone, by accident it was found that it can be used in the extraction of
teeth

Elevator:
When we say elevator (simply), we mean the straight elevator (Copland elevator) - The blade of the elevator is inserted between tooth and bone to create wedging effect that act to raise the tooth - the fulcrum point is located at the adjacent toth Cryer has triangular blade, right or left sides e.g. extraction of lower 6, separation of roost by sectioning into mesial and distal roots by bur, then we apply the Cryer on the distal aspect of the mesial root or mesial aspect of distal root. Warwick James (straight, left, right) Used to extract the upper wisdom tooth, applied mesiobuccally. Apexo elevator its angled with long blade, used for removal of fractured root at a level below that of other instruments can do.

Multiple Extractions
Theres no contraindications of multiple extractions at the same time. For multiple extraction we follow the followings - Extract maxillary before mandibular * if the lower teeth were extracted first, any foreign body can enter the socket during the extraction of upper teeth. - Posterior before anterior * if we started with the anterior teeth, the blood will go back into the patients mouth during the extraction of posterior teeth We skip 2 teeth in multiple extraction, namely the first molar and the canine, first molars have divergent roots and canines have long roots, so we extract the tooth before and the tooth after, this makes the extraction of these 2 teeth easier. In the lower jaw its preferred to extract teeth side by side, because of numbness resulting from local anesthesia, this is better to the patient.

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 POST EXTRACTION CARE :

- Inspect inspect tooth to make sure its integral, no remaining fractures, and inspect the socket for any amalgam pieces or cysts, etc., and then debride the socket. - Squeeze the socket This aids in hemostasis and stop vessel bleeding, and gives the ridge a better fore (U-shaped) this is good prosthowise. - Put pressure pack (gauze) This aids in stopping bleeding and prevent foreign body entry.

POST OPERATION INSTRUCTIONS (to the patient)

- Not to remove the pressure pack for 30 minutes (ask patient for one hour to get the 30 minutes!) - Soft & cool diet (avoid hot diet at all since it induces bleeding). - Not to spit, since spitting may remove the blood clot from the socket which is the most important step in the healing process of the extraction socket? - Not to smoke. - Ice packs on and off - Warm saline after 24 hours - Prescription of NSAIDs. - No need for antibiotics (most of the times)

HEALING OF THE EXTRACTION SOCKET:

- Formation of blood clot (the most important step) - Organization of the clot to make it stable - Epithelialization of the gingiva - Formation of woven bone (1-2 months after extraction) - Replacement of woven bone by trabecular bone and removal of alveolus

DELAYED HEALING (CAUSES):

- Infection - Coagulation defect (e.g. hemophilia A or B), cause prolonged bleeding (no clot = no healing) - Oroantral fistula - Malignant tumor - Radiotherapy, since it makes the bone hypocelluar, hypovascular and hypoxic. - Immunodeficiency - Scurvey (deficiency of vitamin C)

LOCAL COMPLICATIONS OF TOOTH EXTRACTION:

- Fracture of the tooth. - Fracture of the jaw (note: extraction is just to know physics, you dont need excessive forces, extraction without these forces wont cause fracture 23 | P a g e

e.g. isolated lower 8 (no 5,6,7, no adjacent teeth), this tooth has heavy loads and needs force to be extracted and may cause jaw fracture. * if the jaw is fractured its fixed with wires. Note: Theres an exception which is, if theres a remaining fracture of the root (tip) and its less than 1/3 of the root or its 4-5mm in length and theres no infection around it, it can be left in the jaw with follow up. - Opening of the maxillary antrum. * the maxillary antrum has a relationship with teeth 4,5,6,7 & 8 with the closest relationship being the palatal root of the first molar. this opening results in oroantral communication, if its a large opening its closed by flap, if the bone is fractured, we do suturing, give antibiotics and decongestants. - Fracture of maxillary tuberosity the maxillary tuberosity is distal to maxillary 8, if fractured it can cause a communication between the maxillary sinus and the oral cavity (Check for this) How to check for such communication ? * if the blood is coming out with air (something like bubbles) because the sinus contains air. if the fractured piece is small it can simply removed. if its large and resulted in the communication mentioned above return it back, put wires between 7&8,delay extraction for 2 weeks to allow healing of bone and refer the case to a surgeon. - Damage to soft tissue because of slippage of instruments (avoided by careful contol of the instruments) -Loss of tooth * sometimes it can be lost into the buccal or lingual vestibule. * it can be lost into the RS or GIT if it went to the RS, there may be no coughing even (usually theres couging), so we take anterioposterior and lateral X-rays and if its there, its removed by bronchoscopy. if it went to the GIT, it requires no further treatment - Displaced tooth e.g. root tip of lower 8 can be displaced to the ID canal. e.g. root upper 6 can be displaced into the maxillary sinus (it should be removed) - Bleeding * do suction if theres heavy bleeding to know its source (gingiva, socket, etc.) * soft tissue : suturing, Bone : Bone wax ,oxidized cellulose 24 | P a g e

put pressure pack again if theres no medical problem such as hemophilia (in this case we give factor VIII) - Infection, unlikely to occur _DRY SOCKET (ALVEOLAR OSTEITIS) - The most common painful complication of dental extraction. it occurs either due to failure of clot formation (no formation) or dislodgement of the clot (e.g. its formed but the patient is poor compliant and spits thus removed it) - Deep seated, severe, throbbing pain. -Ask the patient : When did it start ? * usually it occurs 48-72 hours after extraction (the characteristic feature of dry socket) - it occurs most of the times in smokers or poor compliant patient (doesnt follow instructions) - Dry = No blood - White bone is dead bone whereas the living healthy bone is yellowish somewhat - in dry socket we see white bone surrounded by red mucous membrane. What to do ? - irrigate the socket - put sedatives or analgesics inside the socket (Alvo G) * not responsive to systemic analgesics. - Its a matter of time!

Part 2:

Medical emergencies in the dental chair: 1- Loss of consciousness The most common cause for this is fainting (vasovagal syncope), vaso = vessels, vagal = related to the vagus nerve which carries parasympathetic fibers, so its the action of parasympathetic system on blood vessels. The figure below illustrates the mechanism of fainting

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Stress

Sympathetic system

Vasoconstriction

BP

BP

Vasodilation

Parasympathetic system

Blood flow to the brain

Fainting

Loss of consciousne ss

The fainting occur when the compensatory mechanism i.e. the activation of parasympathetic system overwhelms the action of sympathetic system. Fainting occurs in people (especially females) with no medical problem, its caused by stress (fatigue, fasting, pain, anxiety, relative hyperthermia, phobia of seeing the needle for example, etc.). In people with relative hyperthermia who cannot tolerate heat, the light of the dental chair should be switched off in between the procedures that need light. The patient will have dizziness, thin and thread pulse, nausea How to react to this problem? - Stop the procedure. - Open the patients shirt. - Put the patient in supine position with elevated legs, this facilitate the blood flow to the brain - patient leave escorted the most important characteristic is monitoring pulse. 2- Acute chest pain It could be due to the muscles of the chest or cardiac. If cardiac it could be angina or MI, both will appear as retrosternal chest pain, heavy, band-like in nature, sometimes radiating to the left arm and lower jaw. 26 | P a g e

Angina is relieved by rest and sublingual nitrates or GTN spray (GTN = glyceryl trinitrate) if the patient didnt respond to these and have sweating, breathlessness, vomiting and irregular pulse it could be myocardial infarction. if we put the patient in supine position we exacerbate the problem So, what to do ? - Put the patient in upright position. - Give analgesia to reduce pain. - Give aspirin (antiplatelet). - Call ambulance. And in hospital they will manage the problem. 3- Anaphylactic reaction the commonest example is the reaction to parenteral penicillin in some patients; also it could be reaction to other things even local anesthesia. The patient will have flushing, itching and some chest symptoms such as wheezing, difficulty in breathing and it could lead to respiratory failure. What to do? - Put a patient in supine position - Give the patient the following drugs: - Adrenaline (raise blood pressure, also its a bronchodilator), SubQ or IM 0.5 mg and repeat after 5 minutes. - Chlorpheniramine (20 mg?), (antihistamine) - Hydrocortisone (dose?) 4- Patient on steroids Corticosteroids are secreted in response to stress to cope with it by increasing the blood glucose levels and blood pressure (also other things) If there is a patient whos taking external corticosteroids for some reason, there will be atrophy in his adrenal gland., if this patient has a stressful condition, he may collapse since the adrenal gland is atrophied and cannot secrete adequate amounts which are needed in this case, so those patients have a problem in dealing with stress. So, what to do if have such a patient in your clinic? - We have to give the patient 100mg hydrocortisone before the procedure (the procedure itself is a stressful condition) - If we didnt give this, the patient will have low blood pressure, low glucose levels, rapid and thin pulse and he might loss his consciousness , in this case the patient is put in supine position and given corticosteroids. 5- Hypoglycemia The most common diabetic emergency. Diabetic patients may have (hyper-) or (hypo-) glycemia, however consider the case to be (hypo-) and react based on this since its much more serious and dangerous. 27 | P a g e

(The patient with hyperglycemia may have acetone breath) if the patient is conscious, ask him to drink some juice (anything containing sugar) if the patient is unconscious he is either given glucose (I.V) or glucagon (I.M). Glucagon opposes the action of insulin.

THANK YOU Muad S.Al-Zoubi

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