Medical

Emergencies
in the
Dental Office
Prepared by
Dr. Shakhawat
Hossain
 Syncope
 Shock

 Hypotention

 Hypoglycemia

 Anesthetic overdose

 Epileptic episode

 Angina

 Myocardial infarct

 Drug allergy

 Anaphylaxis

 Asthma

 Adrenal insufficiency
 ABC OF ANY EMERGENCY

 Supine position
 100 % Oxygen

 Evaluate Airway, breathing ,

circulation
 Vitals
 SYNCOPE
Vasodepressor Syncope
 Most common medical emergency in
dentistry
 30 % of adult population

Etiology
 Decreased cerebral blood flow (CBF)
 The most common reasons for
vasodepressor syncope include: stress,
anxiety, sudden or unexpected pain,
the sight of blood or needles, and
other fear inducing situations
There are various other more serious reasons
why a patient may lose consciousness in the
dental office besides simple fainting. Other causes
of
syncope include:
 drug reaction
 orthostatic hypotension
 epileptic seizure
 diabetic hypoglycemia
 diabetic hyperglycemia
 acute allergic reaction
 variety of heart diseases
 cerebrovascular accident
 hyperventilation

Each of these situations can be life threatening

and require emergency medical assistance.
 CLINICAL MANIFESTATION
Early
 Nausea
 Warmth
 Perspiration
 loss of color
 Baseline Blood pressure
 Tachycardia
Late
 Hypotension
 Bradycardia
 Hyperapnea
 Pupilary dilatation
 Peripheral coldness
 Visual disturbance
 Loss of consciousness
 TREATMENT

 Trendelenburg position
 Pregnant patient lateral decubitus

 Assess consciousness

 ABC

 100 % oxygen

 Vitals ( Bradycardia < 60, administer

Atropine .5mg IV or 1mg IM every 5 minutes
until maximum dose of 3 mg
 EMS if loss of consciousness is > 5 min or if
recovery is > 20 min
 SHOCK
TYPE OF SHOCK
1) Hpyovolumic Shock
2) Cardiogenic Shock
3) Anaphylactic Shock
4) Neurogenic Shock /Vasovagal or
Psychogenic Shock
5) Septic Shock - Hyper dynamic or Warm
Shock
6) Traumatic Shock
7) Burn Shock
 NEUROGENIC SHOCK
 Also known as Vasovagal or Psychogenic Shock.
There is fainting attack caused by intense pain or
sudden fright.
 There is sudden paralysis of vasomotor influence,
causing peripheral vasodilation and fall of
peripheral vascular resistance and pooling of blood
decreases venous return to heart. Decreased
cardiac output and fall of B.P. which causes reflux
vagal stimulation and bradycardia.
 Cerebral hypoxia causes unconsciousness.
 Milder form is treated by removal of offending
stimuli that is relief of pain which causes rapid
gain of vascular tone.
 Severe form is treated by IV fluids and
vasopressure drugs which causes peripheral
vasoconstriction and increase of cardiac output.
 HYPOTENSION
 Following syncope it is the most common
cause of loss of consciousness in the dentall
office

Orthostatic Hypotensiion
 Most common cause of hypotension in the
dental office
 It is Syncope when the patient is placed

quickly from a supine to upright position(<

CBF )
 The second most common cause of loss of
consciousness is orthostatic (or postural)
hypotension.
 Sitting upright or standing can lead to a drop in
blood pressure in some patients.
 Standing systolic blood pressure drops at least
25 mm Hg, and
 Standing diastolic blood pressure drops at least
10mm Hg.
 Groups at greater risk for orthostatic
hypotension include –
the elderly, pregnant, patients reclining for a
long time, patients with Addison's Disease, and
those medicated with nitrous oxide and oxygen,
diazepam, or some drugs used in IV sedation.
 TREATMENT
 Removing the initiating stimuli
 Trendelenburg position

 Oxygen

 Lactated Ringer’s solution 500ml, I/V

 Atropin (if rate <60)

 Ephidrine (if rate>60)

HYPOGLYCEMIA
How are patients going to become
hypoglycemic ?
 Too much insulin
 Alcohol consumption
 Excessive exercise
 Missed delayed meals
 Reduced meals
 Medication error
 Other illness
 SYMPTOMS
Autonomic
1. Sweating
2. Trembling
3. Palpitations
4. Anxiety
5. Nausea

Neuroglycopenic
1. Dizziness
2. Confusion
3. Difficulty speaking
4. Headache
5. Inability to concentrate
6. Weakness
7. Blurred vision
 TREATMENT
 Conscious pt.- Oral glucose
1. Glucose tablets
2. 4 teaspoons of sugar in water
3. 5 oz of regullar soft drink
4. Orange juice
5. Glucagon. dosage : 0..5-1mg
IM or IV
 Unconscious pt.- I/V glucose 50%

 Recheck blood glucose level – every 15

minutes.
 ADVERSE DRUG REACTIONS
WITH
LOCAL ANESTHETICS
Types of local anesthetic reactions

 Local anesthetic toxicity

 Drug interactions
 Vasoconstrictor interactions
 Methemoglobinemia
 Local anesthetics are linked to 50% of the
deaths in the dental office.
 Use the smallest dose that will produce
adequate anesthesia.
 Toxicity can be reached for any anesthetic
by-
1. administering too much of the drug
(especially as related to the patient’s body
weight),
2. administering the drug to a sensitive
individual,
3. administering the drug into a blood
vessel, or
4. by improper drug combinations.
 If the level of the local anesthetic is too high,
it can become toxic causing a dangerous
reaction in the nervous system, cardiovascular
system, or in the local tissues.
 The rate of absorption and elimination of the
drug is directly related to its toxic affects.
 The faster it is absorbed by the bloodstream
and the slower it is metablolized, the more
toxic it is to the body.
 Injection of even a small amount of anesthetic

solution directly into a blood vessel can result

in an immediate toxic level.
 If the patient is overly sleepy or lethargic after

administration of the local anesthetic, it may

be a symptom of toxicity.
 SIGNS AND SYMPTOMS OF LOCAL
ANESTHETIC TOXICITY

1. Slurred speech,
2. Excitement,
3. Shivering,
4. Muscular twitching, and
5. Tremor of facial muscles and extremities.
6. The patient may also feel numbness of the tongue (on
the
opposite side of a mandibular block or in maxillary
anesthesia),
7. Warm, flushed skin,
8. Lightheadedness,
9. Dizziness,
10. Diminished sight,
11. Tinnitus, and
12. Disorientation.
 Maximum recommended doses and toxic limits
(from Malamed Handbook of Local Anesthetics)
Drug Toxic Limit
Maximum
2% Lidocaine (Xylocaine) 2 mg/lb(4.5mg/kg) 300
mg
3% Carbocaine(Mepivacaine) 2 mg/lb 300
mg
4% Citanest (Prilocaine) 2.7 mg/lb 400
mg
1.5% Duranest (Etidocaine) 3.6 mg/lb 400
mg
0.5% Marcaine (Bupivacaine) 0.6 mg/lb 90
mg

 Before administering any anesthetic, calculate the dose of

anesthetic in the cartridge.
 The percent of the solution is the indicator of concentration.

For example, 2% lidocaine is 20 mg of xylocaine per cc of the

drug. Multiply this number by 1.8 (because of the cartridge
containing 1.8 cc. of solution).
So, 2% xylocaine is 20 mg per cc x 1.8cc = 36 mg per cartridge.
So for a 180 lb patient the maximum dose is 2 mg/lb x 180 divided
by 36 mg in the cartridge = 10 cartridges.
But the maximum dose for this drug is 300 mg, which is 8
cartridges.
 ASTHMA
 Asthmatic patients should be reminded to
bring their medication with them to all.
 Attacks can result from exposure to an
allergen,
infection, exercise, cold weather, an inhaled
irritant, or emotional factors.
If a patient were known to have had asthma
attacks due to emotional stress, he or she
would benefit from a stress reduction
exercise before beginning treatment
(especially if he or she indicates a fear of
dentistry).
 Asthmatics should not be prescribed aspirin
and other nonsteroidal anti-inflammatory
drugs or penicillin because they have been
linked to asthmatic attacks.

 Any anesthetic containing bisulfite as a

preservative is contraindicated for use on an
asthmatic patient.
 The patient sits straight up
because it is easier to breathe in this position.
 If the patient has medication, administer it at

this time, according to the directions. If the

patient fully recovers from the episode, the
treatment may continue if the patient and the
Dentist feel it is appropriate.
 The patient should receive medical treatment if
the condition doesn't improve. If the patient's
physician
is unavailable, have the patient transported to
the emergency room. If not treated, respiratory
failure may result.