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ADVANCE MEDICAL EMERGENCY IN DENTISTRY

C Rini Suprapti

KEGAWAT-DARURATAN MEDIK AKIBAT KOMPLIKASI ANESTESI

JENIS ANESTESI DALAM BIDANG KEDOKTERAN GIGI

UMUM (NARKOSE)

LOKAL (TOPIKAL, INJEKSI)

KOMPLIKASI

ANESTESI LOKAL

ANATOMI

FARMAKOLOGI

KOMPLIKASI RANGE: TEMPORARY DISCOMFORT DEATH

Local anesthetics used in dentistry Complication as : Systemic can accur as a result of psychogenic reactions induced by anxiety, toxicity secondary to high levels of the drug in blood or allergy or Localized

Local mandibular block complications


Vascular Neural Osseous Connective tissue Muscular injury from needle penetration Anesthetic deposition or localized hemorrhage

Systemic complications
Syncope Overdose reactions Toxicity Hypersensitivity

SERIOUS MEDICAL EMERGENCY IN THE DENTAL OFFICE

RELATIVELY RARE

MALAMEDS STUDY OF PATIENTS

HYPERVENTILATION SEIZURE HYPOGLYCEMIA

THE THREE MOST COMMON EMERGENCY SITUATION OCCURING IN PATIENTS BEFORE, DURING, OR SOON AFTER GENERAL DENTAL CARE

THESE WERE FOLLOWED IN FREQUENCY BY : SYNCOPE ANGINA PECTORIS HYPOTENTION HYPERSENSITIVITY / ALLERGIC REACTION

PREVENTION

PREPARATION : CONTINUING EDUCATION OFFICE STAFF TRAINING ACCESS TO HELP EMERGENCY SUPPLIES AND EQUIPMENT

PREPARATION FOR MEDICAL EMERGENCIES :

1. PERSONAL CONTINUING EDUCATION IN EMERGENCY RECOGNITION AND MANAGEMENT 2. STAFF EDUCATION IN EMERGENCY RECOGNITION AND MANAGEMENT 3. ESTABLISHMENT AND PERIODIC TESTING OF A SYSTEM TO READILY ACCESS MEDICAL ASSISTANCE WHEN AN EMERGENCY OCCURES 4. EQUIPPING OFFICE WITH SUPPLIES NECESSARY FOR EMERGENCY CARE

MISJUDGING THE ANATOMY CAN RESULT : INADEQUATE OR INCOMPLETE ANESTHESIA NERVE TRAUMA VASCULAR INJURY INTRAVASCULAR, INTRAGLANDULAR, INTRAMUSCULAR INJECTION MIDDLE EAR PROBLEMS EYE PROBLEM

PERSIAPAN
RIWAYAT KESEHATAN LENGKAP TD, NADI PASIEN DALAM KEADAAN RELAX POSISI PASIEN GUNAKAN DISPOSABLE NEEDLE LAKUKAN PENYUNTIKAN PERLAHAN TANPA SAKIT MINIMUM DOSIS ANESTESI LAKUKAN ASPIRASI OBSERVASI SELAMA DAN SETELAH PENYUNTIKAN

Klasifikasi ASA

Various local reactions and complications


Local swelling and pain Trismus Infections and tissue necrosis Muscular complications focal hematoma thromboembolic phenomena reflex vascular spasm abnormal distributions of anesthetic

Adverse neurologic complications affecting local and distant neurologic tracts have been reported following inferior alveolar nerve injections
Complications : cranial nerve paralysis anesthesia of cranial nerve II-VII

Symptoms : ptosis diplopia myosis facial hemiparesis lingual anesthesia Inferior alveolar nerve injections complete and prolonged chorda tympani ageusia or dysgeusia

Permanent nerve injury following the injection of local anesthetic during dental procedures is rare Dental procedure -- inferior alveolar local anesthetic injections ---- > complication-- injury chorda tympani nerve Hypogeusia Ageusia Dysgeusia

Chorda tympani nerve a branch of cranial nerve VII afferent fiber (suply sensory innervation to taste receptors in the anterior two-thirds of the tongue) Sensory information is transmitted to the medulla and on to the cortical taste regions of the brain and efferent fibers (preganglionic parasympathetic fibers to the submandibular and sublingual salivary glands)

Schiffman and Henkin Taste disorders Testing of sense of taste by electrogustometry chemical gustometry !!!! Mandibular or inferior alveolar nerve block anesthesi Harn : 2.075 patients >>> 3.62% chance of traumatizing the lingual nerve with a conventional mandibular block

Seddons original nerve injury classifications (1943) is still often quoted in the medical and dental literature Neuropraxia : a transient nerve dysfunction without significant degeneration and without disruption of axonal integrity. (recovery days-weeks) Axontemesis : a traumatic neural injury with resultant distal degeneration of nerve axons but without disruption of the endoneurium. (recovery about 6-8 weeks) Neurotemesis ( a traumatic neuronal injury with physical disruption and distortion of the nerve structure )

KOMPLIKASI --- ANATOMI


Secara umum ada 4 type : 1. Injuri pada jaringan syaraf 2. Injuri pada pembuluh darah 3. Trauma pada otot 4. Reaksi sistemik Regio kepala dan leher : Ditambah dengan intra glandular yang dapat menimbulkan sekuele

Nerve injury
Paresthesia ( loss of sensation ) tongue lower lip weeks or months Hyperesthesia (increased sensitivity to painful stimuli) Dysesthesia (pain following noxious stimuli)

Proses pasif : Difusi obat anestesi ke daerah orbita mengakibatkan gejala ekstra okular termasuk kelumpuhan otot otot ekstra okular seperti diplopia ( penglihatan ganda ) atau bahkan dapat terjadi kebutaan temporer. Horners syndrome seperti enophtalmos, miosis (pupil konstriksi) dan palpebral ptosis ( droping of the eyelid ) Kadang kadang terjadi temporary loss atau blurring of vision unilateral

Bleeding
Highly vascular area >>> risk >>> intravascular injection, vascular damage, hemorrhage with hematoma formation Vein : bleeding minimal Artery : rapid bleeding with significant hematoma formation Observation at 24-48 hour intervals for any signs of recurrent bleeding or secondary infection of the hematoma

Systemic complications Intra vena local anesthesi sol. Intra arterial injection
Capable of producing systemic toxicity
Patient exitability Elevated heart rate Seizure progressing Loss of consciousness

MANIFESTASI DAN MANAGEMEN REAKSI ALERGI


SKIN SIGNS DELAYED ONSET : ERYTHEMA, URTICARIA,PRURITUS.
STOP DRUG REFER TO PHYSICIAN IMMEDIATE ONSET SKIN SIGNS :ERYTH. URT., PRUR. STOP DRUG EPINEPRINE 0.3 ML 1:1000 SC,IM/IV ANTIHISTAMIN BENADRYL 50 MG IM/IV MONITOR VITAL SIGN REFER OBSERVATION 1 HR

LANJUTAN

RESPIRATORY TRACT SIGNS WITH OR WITHOUT CARDIOVASCULAR OR SKIN SIGNS


WHEEZING, MILD DYSPNEA STOP DRUG SITTING POSITION EPINEPRINE REFER MONITOR

-MODERATE TO SEVERE DYSPNEA : STOP DRUG SITTING POSITION EPINEPRINE OXYGEN VITAL SIGN IV ACCESS IF SIGNS WORSEN TREAT AS ANAPHYLAXIS REFER

ANAPHYLAXIS : MALAISE, WHEEZING,MOD-SEV DYSPNEA, CYANOSIS, TOTAL AIRWAY OBSTR., NAUSEA AND VOMITING, ABDOMINAL CRAMPS, URINARY INCONTINENCE, TACHYCARDIA, HYPOTENSION, CARDIAC DYSRHYTMIAS, CARDIAC ARREST STOP DRUG SUPINE POSITION EPINEPRINE BLS VITAL SIGN CONSIDER CRICOTHYROTOMY IV ACCESS OXYGEN 6 L/MIN ANTIHISTAMIN IV/IM PREPARE TO TRANSPORT

KESIMPULAN
KUNCI UTAMA : PAHAMI ANATOMI FARMAKOLOGI OBAT OBAT ANESTESI PERSIAPAN PADA PASIEN PERSIAPAN ALAT ALAT OBAT OBATAN UNTUK MENGATASI KEADAAN DARURAT SEGERA RUJUK PASIEN KE RS TERDEKAT BILA BLS TIDAK MEMBANTU

BILA BLS TIDAK MEMBANTU ????

ALS

SEGERA RUJUK PASIEN KE RS TERDEKAT

TERIMA KASIH