Management Of

Cardiac
Emergencies In
Dental Practice
Presented by:- Dr. Shruti Singh
Contents

 Introduction
 Risk factors
 Classification
 Prevention
 Preparation
 Chest pain
 Angina pectoris
 Acute myocardial infarction
 Sudden cardiac arrest
Introduction

 Life- threatening emergencies can and do occur in the practice

of dentistry.

 Although the occurrence of life-threatening emergencies in

dental offices is infrequent, many factors are responsible for
such incidents to happen.

 Also, there are some factors which can minimise the

occurrence of such incidents.
Factors Increasing Risk During Dental
Treatment
 Increased number of older patients
Age & Pre-existing disease- ↓ stress tolerance

 Medical advances
 Drug therapy & Surgical Advances have ↑ life
expectancy
 These patients have disorders.. Merely controlled or
managed.. Not cured…

 Increased number of surgical procedures (e.g. Implants)

 Longer appointments
 Medically compromised patients react adversely under stressful
conditions.
 Stress reduction protocol.

 Increased drug use- local anesthetics, sedatives, analgesics ,

antibiotics.

 No drug is absolutely free of risks (drug related emergencies).

 Interactions between various drugs.
Common Medical Emergencies In The Dental
Office
 Unconsciousness - vasodepressor syncope
orthostatic hypotension
acute adrenal insufficiency

 Respiratory Distress- airway obstuction

hyperventilation
asthma
heart failure
acute pulmonary oedema
Altered Consciousness- diabetes mellitus


thyroid gland dysfunction

cerebrovascular accident

Seizures


Drug Related Emergencies- drug overdose reactions



allergy

Chest Pain- angina pectoris



acute myocardial infarction

Sudden Cardiac Arrest


Cardiac Oriented Classification

Non Cardiovascular
cardiovascular
Vasodepressor syncope Angina pectoris
Hyperventilation Acute myocardial infarction
Seizure Acute heart failure
Stress related Acute adrenal Cerebral ischemia & infarction
insufficiency Sudden cardiac arrest
Thyroid storm
Asthma

Orthostatic hypotension Acute myocardial infarction

Overdose(toxic) reaction Sudden cardiac arrest
Non-stress Hypoglycemia
related Hyperglycemia
allergy
PREVENTION
Prevention

 Doctors should be prepared to promptly recognige and

effectively manage medical emergencies.

 McCarthy stated that use of a complete system of physical

evaluation for all patients can prevent 90% of life-threatening
situations.

 Remaining 10% will occur in spite of all efforts.

Prevention

 Physical Evaluation
 Medical history questionnaire

 Physical examination

 Dialogue history

 Psychological examination
 Anxiety questionnaire

 Observation

 Medical history questionnaire

Goals Of Physical Evaluation

 To Determine
 Patient’s ability to physically & psychologically withstand
the stress.
 whether treatment modifications are required to enable the
patient to better tolerate the stress.
 Whether the use of psychosedation is warranted

 Which sedation technique is most appropriate

 Whether contraindications exist to any of the drugs to be
used in the planned treatment.
Medical History Questionnaire
 Moral & Legal Necessity.

 Information about the physical and psychological condition of the

patient.

 Valuable when doctor is able to interpret the significance of the answers

and elicit additional information through physical examination and
dialogue history.

 Two types: short form

long form
Physical Examination

 Monitoring vital signs

 Temperature
 Heart rate (pulse & rhythm)
 Respiratory Rate
 Blood Pressure
 Height & Weight
 Visual inspection
 Function test as indicated
 Auscultation, monitoring (ECG) & lab tests for heart & lung
as indicated.
 Physical examination provides the doctor with important
current information about the patient’s physical status.

 Physical examination should be completed at an initial visit

before the treatment is started.

 Vital signs obtained at the preliminary appointment is known

as baseline vital signs.
 Determines the ability to tolerate stress.
 used as standard during emergency.
Vital Signs By Age
Dialogue History

 Discussion with the patient about significant finding detected

through physical examination and medical history
questionnaire.

 Doctor must use all available knowledge of the pathological

process to assess the degree to which patient is at risk.
Anxiety Recognition

 Heightened anxiety & fear of dentistry→ acute exacerbation

of medical problems.

 One of the goal of patient evaluation is to determine

psychological capacity to tolerate stress.

 Methods of anxiety recognition-

1. Medical History Questionnaire
2. Anxiety Questionnaire
3. Observation
Psychological Examination

 Medical History Questionnaire

 Patient’s attitude towards dentistry
 Negative dental experiences

 Dental Anxiety Questionnaire

 devised by Dr. Norman Corah
 answers to individual questions are scored 1-5 with a=1 and e=5
 Maximum possible score is 20
 Scores of 8 and above show high anxiety and need to be addressed by
doctor.

 Observation
Observation

Clinical signs of moderate anxiety-

RECEPTION AREA IN DENTAL CHAIR

1. Questions to receptionist
regarding injections.
2. Nervous conversations
with other patients.
3. History of emergency
dental care only
4. History of cancelled
appointments.
5. Cold, sweaty palms
1. Unusually stiff posture
2. Nervous play
3. White knuckle
syndrome
4. Perspiration
5. Over willingness to
Cooperate
6. Quick answers

A moderately anxious patient is usually treatable by

iatrosedation or pharmacosedation techniques.
 Clinical signs of severe anxiety-
 Increased BP and HR

 Trembling

 Excessive sweating

 Dilated pupils

 Severely anxious patients can be managed by iv sedation or

general anesthesia.
Determination Of Medical Risk

 After complete examination & thorough history following

questions must be answered….

 Is patient capable of tolerating the procedure?

 Is patient at greater risk than usual?

 Treatment modifications, if any?

 Potential of the risk…. Whether it can be managed in dental

setup or not?

 Patient assessment can be done by ASA Physical Status

Classification System
ASA Physical Status Classification System

 Adopted in 1962 by American Society of Anaesthesiologists.

 Primarily designed for G.A., but since its introduction used

for all surgical procedures regardless of anesthetic technique.

 When it was adopted for use in an outpatient dental setting

ASA-V Classification was eliminated.
ASA Classification

 ASA-I
 Normal, Healthy patient

 ASA- II
 Mild, systemic disease present

 ASA-III
 Severe systemic disease that limits activity but not
incapacitating.
 ASA-IV
 Incapacitating systemic disease that is a constant threat
 ASA-V
 Moribund patient not expected to survive more than 24hrs
with or without an operation.
 ASA-VI
 Brain dead patient whose organs are being removed for
donor purpose
 ASA-E
 Emergency operation of any variety

 (ASA E- III)
Dental Considerations of ASA Classification

 ASA-I
Normal & healthy patients. “Green light”
 Able to walk up one flight of stairs without distress.

 able to tolerate whatever stress associated with planned Rx.

 Psychologically may have little or no difficulty.

 Treatment modification usually not required

 ASA-II
Has mild systemic disease or is healthy but may show extreme
anxiety & fear. “Yellow light”
 Able to walk up one flight of stairs before distress causes them to
stop.
 Less stress tolerant
 Includes well controlled Type-2 DM, Epilepsy, Asthma, Thyroid
disorders
 ASA-I Patient with URTI, ASA-I Pregnant Patient
 Healthy patients >60yrs
 Treatment modifications such as prophylactic antibiotics, sedation,
limiting duration of treatment and possible medical consultation.
 ASA-III
Severe systemic disease that limits activity.
 Distress exhibited only on psychological or physiologic
stress.
 Serious consideration to Rx Modification.

 E.g. Stable Angina, Post MI- >6 months , well controlled

Type-I DM, Heart Failure with Orthopnea,
COPD, Exercise induced Asthma, Epilepsy (controlled),
Thyroid Disorders
 ASA-IV
Incapacitating systemic disease which is a constant threat
to life.
 Severe medical problems which are of greater significance
than dental Rx
 Whenever possible post-pone the dental Rx or else it
should be non invasive.
 E.g. Unstable Angina, MI within past 6 months, Severe HF
or COPD, uncontrolled Epilepsy, uncontrolled Type I DM
 BLOOD ASA DENTAL THERAPY CONSIDERATION
PRS. CLASSIFIC
(mm Hg or ATION
Torr)

<140 & <90 I 1. Observe routine dental management.

2. Recheck in 6 months
140-159 &/or II 1. Recheck for 3 consecutive appointments.
90-94 2. If exceeds medical consultation
recommended.
3. Observe routine dental procedure.
4. Implement stress reduction protocol.

160-199 &/or III 1. Recheck in 5mins. Persists, refer for medical

95-114 consultation.
2. Observe routine dental procedure
>200 &/or IV 1. Recheck in 5mins.
>115 2. Perform immediate medical consultation
3. Do not perform dental Rx.
4. EMERGENCY Rx can be done with the help
of drugs after B.P. comes down to
acceptable.
5. Ref. to hospital for immediate dental Rx.
Medical Consultation

 Obtain patient’s medical and dental histories.

 Complete the Physical Examination …oral and general.

 Provide a tentative treatment plan based on patient’s oral

needs.

 Make a general systemic assessment (choose ASA category)

 Consult patient’s physician.

 Discuss treatment plan, medications to be used, degree of

stress anticipated and any other problems.

 After consultation write records and obtain a written report

from physician.

 Obtain patient’s consent.

Stress Reduction Protocol

Healthy anxious patients (ASA-I)

 Recognize level of anxiety.

 Premedicate an evening before, if needed or immediately

before the treatment.

 Morning appointment.

 Minimize waiting time

 consider psycho-sedation.

 Administer adequate pain control.

 Length of appointment variable.

 Follow up with post-op pain & anxiety control.

 Telephone the highly anxious patient later the day Rx was

delivered.
Medical Risk Patient (ASA II,III, IV)

 Recognize the degree of medical risk.

 Medical consultation before dental Rx, as needed.

 Morning appointment.

 Monitor and record preoperative and postoperative vital signs

 Consider pyschosedation .
 Adequate pain control.

 Vary the length of appointment.

 Follow up with post-op pain & anxiety control.

 Telephone the patient later on the same day.

 Arrange the appointment of highly anxious, moderate-high

risk patient during first few days in the week.
Dental Procedures & Endocarditis Prophylaxis
RECOMMENDED NOT RECOMMENDED
Extractions,
 Periodontal
procedures- Scaling & Restorative dentistry
Root Planing
LA Injection (Non intra-
Surgery, Probing, Recall
ligamentary).
maintenance
Placement of rubber dam,
Implant placement &
Post-op suture removal
Re-implantation, RCT.
Placement of removable
Sub gingival placement
prosthodontic & ortho
of antibiotic fibers or
appliances
chips.
Impression making,
Initial placement of
Fluoride Rx, Radiographs
orthodontic bands.
Intraligamentary Local
PREPARATION
 Emergencies can & do occur in dentistry.

 Entire staff should be prepared to

 Assist in recognition

 Management.

 Doctor must know steps of Basic Life Support (BLS) or

Cardiopulmonary Resuscitation (CPR)

 In all circumstances it is advisable to summon medical

assistance.
General Principles

1. Follow the Airway, Breathing, Circulation, Definitive,

and Exposure approach (ABCDE) to assess and treat the
patient.

2. Treat life-threatening problems before moving to the next

part of the assessment.

3. Continually re-assess starting with Airway if there is further

deterioration.
4. Assess the effects of any treatment given.

5. Recognize when you need extra help and call for help early.
(dial for an ambulance 108)

6. Use all members of your dental team. This will allow you to
do several things at once, e.g., collect emergency drugs and
equipment, dial EMS.
7. Organize your team and communicate effectively.

8. The aims of initial treatment are to keep the patient alive,

achieve some clinical improvement and buy time for further
treatment while waiting for help.

9. Remember - it can take a few minutes for treatment to work.

Basic Life Support (BLS)

 Step-1
 Check responsiveness
 Shake the patient.
 Shout patient’s name.

 Step-2
 Summon assistance and P-position the patient
 Members of office emergency team should be called.
 Emergency drug kit, oxygen, AED must be arranged by a member.
 Place the patient in supine position on a flat and firm surface.
 Head and chest should be parallel to the floor and feet slightly elevated.
 Step-3
A- airway- assessment & correction
If airway is not free, following is noticed:
 Gurgling, snoring or croaking sound heard in the throat.
 While breathing, chest and abdominal movements are like
see-saw movement.
 Accessory muscles of respiration (neck muscles) are
prominent or straining.
 Patient is restless, agitated (lack of oxygen).
 Patient turning blue (cyanosis).
 To obtain a patent airway:
Triple maneuver:
1. open the mouth – clear the airway
2. head tilt and chin lift
3. jaw thrust

 Head tilt and chin lift:

- place one hand on the victim’s forehead and apply firm backward
pressure to tilt the head back
- place the fingers of the other hand under the bony part of the chin
- lift the chin forward and support the jaw
 Jaw thrust:
- grasp the angle of the victim’s lower jaw and lift with both
the hands, one on each side, displacing the mandible forward,
while tilting the head backward.
- insert an oro-pharyngeal airway if available.
 Step-4
B-breathing-Assessment & assistance
Check for breathing by:
 Look- for chest wall movement.

 Listen- for sounds of breathing by placing the ear 1 inch from

the patient’s mouth or nose.

 Feel- for warmth of air breathed out by placing the back of the

hand below the nostril.

Expired air resuscitation, if there is no breathing:
 Mouth to mouth breathing

 Mouth to nose breathing

 Mouth to airway breathing

 MOUTH TO MOUTH BREATHING
 Open the airway with triple maneuver.

 Close the patient’s nostrils with thumb and index finger.

 Take a deep breath and form a seal with lips around the
patient’s mouth before exhaling.

 Exhale into patient’s mouth completely .

 Observe for chest expansion.

 Repeat 2 times without allowing patient to exhale.

 Give 1 breath every 5-6 seconds (10-12 breaths per minute).

 Check the pulse in about 2 minutes.

 A pocket face mask can also be used.

 Step-5
C-circulation- assessment & treatment
 If patient is not breathing, check for check for carotid pulse.

 Carotid pulse present- continue mouth to mouth respiration.

 Carotid pulse absent- start CPR.

 Activation of EMS.
 One rescuer technique

 Breathe 2 consecutive breaths into the patient’s mouth

followed by 30 chest compressions.
 Chest compressions should be at the rate of about 100 per
minute.
 Check for carotid pulse every 2 minutes.
 Continue CPR till carotid pulsations are felt or help arrives.
 Simultaneously call for help/ambulance/AED.
 Two-rescuer technique

 1 person provides artificial breathing and the other cardiac

compressions.
 Provide 2 artificial breath for every 30 chest compressions.
 Chest compression rate is 100 per minute.
 Check for carotid pulse every 2 minutes.
 Switch the roles between 2 persons every 2 mins or after 5
cycles.
 Continue CPR till carotid pulsations are felt or help arrives.
 Technique of chest compressions:

 Position yourself on patient’s side.

 Patient should be lying on his back on a firm, flat surface.

 Place the heel of one hand on the lower half of sternum in the
middle of chest.

 Place the heel of other hand over the first and lock your fingers.
 Straighten your arms and position your shoulders directly over your hands.

 Press the chest directly downwards 1.5-2 inches with each compression.

 At the end of each compression, make sure chest recoils completely.

 Minimize interruptions in chest compressions.

 Rate of compressions - 100 per minute.

 Compression-ventilation ratio- 30:2.

 Step-6
Defibrillation
 Early defibrillation increases the chance of survival.

 Automated external defibrillators (AED) are used when

patient does not respond after 4-5 cycles of CPR.

 AED should be used as soon as it is available.

 A brief period of CPR (1.5-3 mins) before defibrillation

improves return of spontaneous circulation
 Put the AED next to patient and switch on the AED and follow
voice prompts.

 Attach adult AED electrode pads to the bare skin of the patient as
per diagrams on electrodes.

 Allow the AED to analyze the heart rhythm.

 Be sure that no one is touching the patient and deliver shock.

 Start CPR immediately after shock delivery.

Emergency Drug Kit

 Three things must be kept in mind…

1. Drug administration is NOT necessary for immediate

management.

2. Primary management always includes BLS for ALL

situations.

3. When in doubt don’t medicate

Components Of Emergency Kit

 Selection should be done of only those categories of drugs

with which doctor is familiar & able to use.

 One must know indications, usual dose, adverse reactions &

expiry dates .

 Emergency drugs & equipments are categorized in four

modules.
 Module-I
Basic emergency kit
Contains critical drugs & equipment
 Module- II
Non critical drugs & Equipment
 Module- III
ACLS Drugs
 Module- IV
Antidotal Drugs
 Module-I
(Critical Drugs)
INJECTABLE NON-INJECTABLE EQUIPMENTS
DRUGS DRUGS

•Epinephrine •Oxygen •O2 Delivery System

•Chlorpheniramine/ •Nitro lingual Spray/ •Automated Electronic
Diphenhydramine Tablets Defibrillator
•Albuterol/ •Syringes
Metaproterenol •Suction & Suction Tips
•Sugar/ Insta Glucose •Tourniquet/
Gel Sphygmomanometer
•Aspirin •Magill Intubation
Forceps
 Module-II
(Non Critical Drugs)
INJECTABLE NON-INJETABLE EQUIPMENTS

Midazolam/ Diazepam Aromatic Ammonia Scalpel/ Cricothyrotomy

Morphine/ Meperidine Nifedipine needle
Phenylephrine Artificial Airways
50% Dextrose Laryngoscope &
Hydrocortisone/ Endotracheal Tubes
Dexamethasone Laryngeal Mask Airways
Esmolol/ Propranolol
Atropine/ Scopolamine
 Module-III
(ACLS Drugs)
INJECTABLE NON-INJECTABLE

Epinephrine (1:10,000) Oxygen

Morphine Sulphate/ N2O-O2
Lidocaine/ Procainamide
Atropine/ Isoproterenol
Verapamil
 Module-IV
(Antidotal Drugs)

Category Drug Quantity Availability

Opioid Antagonist Naloxone/ 2*1 ml Ampules 0.4 mg/ml
Nalbuphine
Bzd Antagonists Flumazenil 1*10 ml Vial 0.1 mg/ml

Anticholinergic Physostigmine 3*2 ml Ampules 1 mg/ml

Toxicity

Local Anaesthetic/ Procaine 2*2 ml Ampules 10 mg/ml

Vasodilator
Epinephrine

 Indication:
allergic reactions
asthmatic attack
cardiac arrest

 Contraindication/side-effect:
tachydysrhythmia
pregnant women
Availability-
1:1000 for IM & SC administration only
1:10000 is for IV administration.

Dose-
Unit dose/ therapeutic dose- 0.3 mg
1:1000- Acute allergic reactions
1:10000- Cardiac Arrest

Each kit should have one preloaded syringe & 3-4 ampules of 1:1000
epinephrine.

Overdose- cerebrovascular haemorrhage

Oxygen

 Most useful drug in entire kit.

 Available in various sizes of compressed gas cylinders. Recommended is

‘E’ size cylinder which is portable.

 Provides O2 for approx. 30 mins.

 Indicated in any emergecy situation with respiratory distress.

 Not indicated in hyperventilation.

 Minimum one E cylinder should be kept in the kit.

Nitroglycerin

 Vasodilator

 Immediate management of chest pain.

 Available in tablet & spray form.

 Acts in 1-2 mins.

 Generallypatient’s own drug should be used. But kit should also contain
0.4mg drug.

 Shelf life of opened tablet is 12 weeks.

  nitroglycerin tablet when placed sublingually produces a
bitter taste. Absence of bitter taste means drug has become
ineffective.

Side effects/contraindications:
 Produces pulsating headache, facial flushing & some
hypotension(upright).
Availability:
 0.3, 0.4, 0.6 mg- sublingual tabs
 0.4, 0.8 mg translingual spray
 0.4 mg should be kept in the emergency kit.
Albuterol

 Bronchodilator.

 Asthmatic &patients with allergic reactions.

 Specific bronchial smooth muscle relaxing properties.

 This has less significant cardiac effects hence selected as emergency drug.

 Available as inhalers.

1 or 2 inhalations every 4-6 hrs is the recommended dosage.

 One metered inhaler should be kept in the kit.

Orange Juice

 Antihypoglycaemic.

 Management of hypoglycaemia.

 In conscious patients, sugar source such as candy bar is useful.

 Thick non-viscous forms of carbohydrate may be used known as

transmucosal application of sugar.

 When a patient is unconscious 30ml of 50% dextrose solution is given IV.

 If IV route is not available 1mg glucagon can be given IM.

Aspirin

 Antiplatelet.

 Recommended in management of patients with suspected

myocardial infarction or unstable angina.

 Standard dose range is 160-325mg orally.

 Minimal side effect with 160 mg dose.

 Major side effect- risk of hemorrhage.

CHEST PAIN
 Most Common cause of chest pain

 Angina Pectoris
 Hyperventilation
 Myocardial Infarction

 Major Etiologic Factor

 Atherosclerosis

 Most Common Artery Susceptible to atherosclerosis

 Anterior Descending Branch of Left Coronary Artery

Causes Of Chest Pain

 Cardiac related  Non cardiac

 Pleuritic e.g., pulmonary

embolism
 Angina pectoris  Musculoskeletal

 Esophageal reflux

 Hiatal hernia
 Myocardial infarction  Hyperventilation

 Peptic ulcer

 Cholecystitis

 Acute indigestion

 Intestinal gas

 Aortic aneurysm
Coronary Heart Disease

 Coronary Heart Disease can be defined as narrowing or an

occlusion of coronary arteries usually by atherosclerosis that
results in imbalance between requirement for & the supply of
oxygen to myocardium leading to myocardial ischemia.
Predisposing factors

 Dyslipidemia
 Total cholesterol level- ≥240mg/dl; LDL ≥160mg/dl,
triglycerides >200mg/dl, <40mg/dl HDL
 Smoking
 Hypertension
 Insulin resistance & Diabetes Mellitus
 Decreased Exercise & Obesity
 Stress
 ↑ adrenergic stimulation.. ↑myocardial O Req.→MI
2

 Estrogen Status
Angina Pectoris

 Angina ..Latin word…spasmodic cramp like, choking feeling

or suffocating pain

 Pectoris…chest

 First used By Dr. William Heberden in 1768.

Angina Pectoris

 Defined as a characteristic thoracic pain, usually sub sternal;

precipitated chiefly by exercise, emotion or a heavy meal;
relieved by vasodilator drug & a few minutes rest; & a result
of moderate inadequacy of the coronary circulation
Precipitating Factors

 Physical Activity
 Hot, humid environment
 Cold weather
 Large meal
 Emotional stress
 Caffeine ingestion.
 Fever, anemia, cigarette smoking
 High altitudes
 Second Hand Smoke
 Types of Angina
Synonyms Duration Type Response to
Nitroglycerine

Stable Chronic, Classic, 1-15 mins Emotional Good

Exertional stress, physical
exertion, cold
weather, eating.

Variant Prinzmetal’s, atypical, Variable Coronary Good

vasospastic Artery Spasm

Unstable Preinfarction, Up to 30 Any Factor ?

Crescendo, Acute Mins
Coronary Insufficiency,
Intermediate Coronary
Syndrome, Impending
MI
 Clinical Characteristics
CHARACTERISTIC LIKELY TO BE ANGINA LESS LIKELY TO
BE ANGINA
Type of Pain Dull, Pressure like Feeling Sharp, Stabbing

Duration 2-5 Mins. Always <15-20 mins Seconds to hours

Onset Gradual Rapid

Location Substernal may radiate to neck, Lateral chest wall,
jaw, left arm, upper Epigastric Back
region
Reproducible With exertion With Inspiration
Associated Symptoms Present Absent

Palpation of Chest Not Painful Painful

wall
Clinical Manifestations

 Pain originates behind sternum & may radiate to

 Either of the upper extremities
 Neck, jaws & teeth
 Upper back
 Superior middle abdomen

 Shortness of breath, nausea

 Usually pain lasts for 3-5 mins & lasts throughout the attack not
influenced by position, breathing or coughing.

 Diminishes when physical or emotional stress ends

Prevention

 Medical History Questionnaire

 Have you experienced chest pain or shortness of breathe?

 Do you have or have you had heart disease, heart attack, high B.P.
or h/o diabetes mellitus?

 Any h/o of hospitalization or surgery?

 Are you taking drugs, medications such as anti-platelet

medications or aspirin?
 Dialogue History
 Describe a typical anginal episode

 Where does pain radiate

 How long your anginal pain last

 What precipitates it

 Frequency

 Any associated symptoms

 Physical Examination
 Vital signs
Dental Considerations

 Use of Effective Stress Reduction Protocol

 Length of appointment

 Use of supplemental O2 via nasal cannula or nasal hood

 Use of effective pain control during therapy

 LA with epinephrine-0.04mg

 Psychosedation
Diagnostic Clues

 H/O angina
 Onset with exercise
 Stress
 Pressure
 tightness
 heavy weight
 substernal, Epigastric, jaw pain
 mild to moderate discomfort
Management

 Termination of dental procedure

 Activation of office emergency team

 P-Position the patient comfortably (sitting or standing upright)

 A-B-C Assess airway, breathing and circulation

 D-Definitive care
 In patient with h/o angina:

 administer nitroglycerin tablet sublingually, 0.3-0.6 mg. can be

repeated upto 3 times in 5 mins interval.

 Administer oxygen.

 If pain resolves, consider future dental treatment

modifications, monitor and record vital signs.

 If pain does not resolve, activate EMS, administer aspirin,

monitor and record vital signs.
 In patient with no h/o angina:

 activate EMS stat

 administer oxygen and consider nitroglycerin

 monitor and record vital signs

Acute Myocardial Infarction

 Myocardial infarction is a clinical syndrome caused by a

deficient coronary artery blood supply to a region of
myocardium that results in cellular death & necrosis.

 It is usually characterized by severe & prolonged sub sternal

pain similar to, but more intense & of longer duration than
that of angina pectoris.
Predisposing Factors

 Coronary artery disease (Atherosclerosis)

 Obesity
 Male gender
 Undue stress
 Strong family history of Cardiovascular Disease.
 Dyslipidemia
 Hypertension
Prevention

 Medical history questionnaire

 Have you ever experienced chest pain, swollen ankles, shortness
of breath?
 Do you have or had heart disease, heart attacks, stroke, high
blood pressure?
 Are you taking drugs for any disease?

 Dialogue history
 When

 Pattern of episodes

 Hospitalized, any medication

 Physical examination
 Peripheral cyanosis

 Peripheral edema

 Orthopnea

 Coolness of extremities

 Vital signs
Clinical Manifestations
 Signs  Symptoms
 Restlessness
 Acute distress
 Skin-cool, pale, moist
 HR- bradycardia to
tachycardia
 Dyspnea
 Pain
Severe to intolerable
Prolonged, 30 min
Can occur during rest
Crushing, Choking
Retrosternal
Radiating
 Nausea and vomiting
 Weakness
 Dizziness
 Palpitations
 Cold perspiration
 Sense of impending doom
Dental Considerations

 ASA II,III or IV depending on the time elapsed after attack.

 Stress Reduction Protocol must be used.

 Administration of supplemental O2.

 Use of sedation, adequate pain control.

 Short duration of appointment

 No treatment- at least 6 months after MI.

 Medical consultation is indicated if patient is on anticoagulant

therapy.

 Elective dental treatments can be done if INR is 2-3 without

altering anticoagulants dose.
Difference

ANGINA
 Pain follows exertion or
stress
 Lasts for 3-5mins
 Relieved by rest,
nitroglycerine
 Not associated with
arrhythmias.
 Blood Pressure usually not
affected
MI
 Often related to stress but
may also occur at rest.
 Lasts for > 30mins
 Not relieved by rest,
Nitroglycerine
 Associated with
arrhythmias
 BP often Reduced.
Management

 Termination of dental procedure

 Activation of office emergency team

 Position the patient comfortably (upright)

 A-B-C assess airway, breathing and circulation

 D- definitive management
 In patient with h/o angina:

 administer nitroglycerin tablet sublingually, 0.3-0.6 mg. can be

repeated upto 3 times in 5 mins interval.

 Administer oxygen.

 If pain resolves, consider future dental treatment modifications,

monitor and record vital signs.

 If pain does not resolve, activate EMS.

 In patient with no h/o angina:

 Activate EMS, stat

 Administer oxygen

 Consider nitroglycerin (should not be given in hypotension)

 Antiplatelet therapy
 aspirin 160-325 mg orally
 clopidogrel 300mg orally
 Pain relief
 iv administration of 2-5 mg of morphine sulphate every 5-30 mins.
 a mixture of N2O (35%) and O2 (65%) by nasal hood.

 Monitor and record vital signs every 5 mins

 Preparation to manage complications

 CPR
 Emergency drugs

 Stabilize the patient and transfer to hospital.

Cardiac Arrest

Cardiac arrest is broadly defined as the “inability of the heart

to sustain an effective output.”

By definition, the patient is in full cardiac arrest if he/she:

 Is not responsive

 Is not breathing

 Has no pulse

 Auscultation of the heart: absence of heart sounds

 Pupils: may be dilated with a sluggish or no reaction to light

 Skin color: there may be pallor or cyanosis

Ischemic heart Acute complications
diseases • Cardiac Cardiac arrest,
• Angina dysrhythmia Sudden cardiac
• MI • Cardiopulmonary arrest, sudden death
• Heart failure collapse
Etiology

 Myocardial infarction

 Sudden cardiac arrest

 Airway obstruction

 Drug overdose

 Anaphylaxis

 Seizure disorders

 Acute adrenal insufficiency

Management

 Cardio-Pulmonary Resuscitation (CPR) is most effective

when done immediately.

 Outside the hospital- BLS (basic life support),

inside the hospital- BLS + ACLS (advanced cardiovascular
life support) & post resuscitation life support, in short
called as cardiac pulmonary cerebral resuscitation (CPCR)
 Use of AED as early as possible.

 Epinephrine 1:10000 conc. 10 ml of preloaded syringe i.v.

 Administer oxygen.
References

 Medical emergencies in dental office, Stanley F. Malamed. 6th edition.

 Essential of medical phamocology. K D Tripathi, 5th edition.

 Dentist’s guide to medical emergencies & complications, Kanchan Ganda.

 Medical emergencies & resuscitation, Statement from resuscitation

council, UK