PREVENTION AND

MANAGEMENT OF
MEDICAL EMERGENCIES
Dr. Noorul Ain Arshad
Assistant professor
Oral and maxillofacial surgery deptt, MM&DC
Multan
PREVENTION
 RISK ASSESSMENT
 CONTINUING DENTAL EDDUCATION
 TRAINED AUXILIARY STAFF
 ESTABLISHING A SYSTEM TO GAIN READILY

ACCESS TO MEDICAL HEALTH CARE FACILITY

 EQUIPING THE OFFICE WITH EMERGENCY

EQUIPMENTS AND MEDICINES

Drugs and equipment
 Portable apparatus for oxygen administration
 Oxygen facemask
 basic set of oro-phyryngeal airway
 Ambo bag
 Portable suction
 Spacer device for bronchodilator
 automated external defibrillator
 Single use sterilized syringes
 Adrenaline injection 1:1000 1mg/ml
 Oral glucose solution, glucagon injection 1mg
 salbutamol aerosol (Beta-2 agonist) inhaler
 Injection midazolam 10mg/ml
 Nitroglycerin spray 400mcg/ metered

activation
 Dispersible aspirin 300mg
1.Fainting (vasovagal syncope)
Causes
 Anxiety
 Pain
 fatigue
 high temperature and humidity

Manifestations.
 Tachycardia and palpitations, generalized warmth,

weakness or nausea
 Dizziness and hypotension
 Baradycardia
 Loss of consciousness
pathophysiology
 Anxiety Sympathetic stimulation

pooling of blood in periphery

increased heart rate/compensatory
mechanism
decompensation/feedback
mechanism decreased blood
pressure/reduced cerebral blood
flow/syncope
managment
 Prevention
 Prodromal phase
◦ Terminate all dental procedures
◦ Reassurence
◦ Chair positioning
◦ Place cool towel on forehead
◦ Monitor vital signs
 Syncope episode
◦ Chair positioning
◦ Loose tight clothing around neck
◦ Usually rapid recovery no recovery

◦ Reassurance and defer treatment use reparatory stimulant

check BP and pulse administer oxygen
give 100mg hydrocortisone assess need for
BLS and call for help
Differential diagnosis
 Hypoglycemia
 Adrenocortical insufficiency
 Myocardial infarction
 Cardiac arrest
 Stroke
 Hypersensitivity
 Toxicity
 Epilepsy
Hypoglycemic shock
 Common in diabetic patients
◦ Missed, delayed or inadequate meal
◦ Insulin overdose
◦ Unusual exercise
◦ Malabsorption
◦ alcohol
Hypoglycemia vs hyperglycemia

HYPERGLYCEMIA
Slow onset
HYPOGLYCEMIA Drowsiness/
Rapid onset disorientation
Irritability/aggression. Dry skin dry mouth
Moist sweaty skin Weak pulse
Pulse full and rapid Blood sugar raised
Blood sugar low Ketonuria
Acetone breath
hyperventilation
Management of hypoglycaemia
 Terminate all dental procedures
 Lay patient flat or head down the level of legs
 Obtain blood sugar levels
 If Patient conscious Administer glucose

source by mouth
 monitor vitals
 If no improvement or unconscious pt then

20ml of 25% to 50% glucose or 1mg glucagon

IM
 Consult physician
Local anesthesia toxicity
Manifestations
 Mild toxicity: Talkativeness, anxiety, slurred

speech and confusion

 Moderate toxicity: strutting speech,

nystagmus, tremors, headache, blurred vision
and drowsiness

 Severe toxicity: seizures, cardiac

dysarrythmias or arrest
Management of LA toxicity
 Stop all treatment n LA
 Monitor vitals and observe the patients for 1hr
 Place in supine posture
 Give oxygen if condition worsens or becomes
unconscious
 Do suction and protect from nearby objects
 Monitor for 1 hr
 If seizures occur give diazepam 10mg IV
slowly, give oxygen, institute BLS if necessary
and transport to emergency
Hypersensitivity reactions
 Manifestations and management
◦ Delayed onset skin reactions:
erythema, articaria, pruritus, angioadema
◦ Management
 Stop the drug
 Administer an antihistamine intavenously or
intramuscularly
 Refer to physcian
 Priscibe oral antihistamine
Hypersensitivity reactions
 Immediate onset skin reactions
◦ Erythema, articaria, pruritus
 Management
◦ Stop drug administration
◦ Administer epinephrine .3 ml in 1:1000 IV or IM
◦ Administer antihistamine IV or IM
◦ Monitor vital signs
◦ Consult physician and observe in office for 1 hour
Hypersensitivity reactions
 Respiratory tract signs with or without
cardiovascular or skin signs
◦ Wheezing , mild dysnea
 Management
◦ Stop the drug in use
◦ Administer epinephrine
◦ Provide IV access
◦ Observe in office and consult physician
◦ Prescribe antihistamine
Hypersensitivity reactions
 Strider breathing i.e moderate to severe
dyspnea
◦ Stop the drug in use
◦ Sit the patient upright and have seek medical
assistance
◦ administer epinephrine
◦ Give oxygen
◦ Administer antihistamine
◦ If signs worsen or persist treat as for anaphylaxis
◦ Prepare for transport to emergency
Hypersensitivity reactions
 Anaphylaxis (with or without skin reactions)
◦ Wheezing, strider, cyanosis, total airway obstruction, nausea
vomiting, abdominal cramps, urinary incontinence,
tachycardia, hypotension, dysrhythmias and cardiac arrest
 Managemnt
◦ Stop administration of all drugs
◦ Position patient supine on back board and seek medical
assistance
◦ Administer epinephrine
◦ Initiate BLS and monitor vital signs
◦ Consider cricothyrotomy
◦ Give oxygen
◦ Administer epinephrine
Chest Discomfort
 Angina pectoris, myocardial infarction
 Dyspepsia, gastric ulcers, reflex esophagitis.
 Intercostals muscles spasm, rib or chest

muscle contusions
 Hyperventilation or psychogenic chest pain.
 Clinical characteristics of acute chest pain
caused by Myocardial infarction
◦ Squeezing, bursting, pressing, burning, chocking,
or crushing
◦ Substernelly located with variable radiation to left
shoulder, arm, or left side of mandible
◦ Associated with exertion, heavy meal or anxiety
◦ Relieved by vasodilators or rest
Management
 Terminate all dental procedures
 Position the patient in semi-reclined position
 Give nitroglycerin tablet sublingually
 Give oxygen
 Check blood pressure and pulse
 If discomfort is relieved assume angina is

present
 slowly taper oxygen over 5 mints. Modify

dental treatment to avoid recurrence

 If Discomfort continues 3 mints after TNG
◦ Give second TNG dose
◦ Monitor vital signs
 Discomfort relived than assume angina .
Taper oxygen. Modify treatment
 If discomfort is still not relived TNG 3 mints

after TNG
◦ give third dose of TNG and monitor vital signs and
seek medical assistance
 If discomfort relived than refer the patient for
further medical evaluation
 If discomfort is still not relieved 3 mints after
TNG
◦ Assume myocardial infarction is in progress
◦ Give 352 mg of aspirin
◦ Start IV line and crystalloid solution at 30 ml per hour
◦ If severe discomfort, can titrate morphine sulphate 2
mg subcutaneously or intravenously every every 3
mints until pain is relived
◦ Prepare to transport and assess the need for BLS
 If blood pressure ever falls below 90 systolic
or 50 diastolic, withhold TNG and Morphine.
Wait for the medical assistance
Hyperventilation
 Frequent cause is anxiety
 Complain of inability to get enough air and

patient breath rapidly

 Rapid breath eliminate co2 through lungs

which leads to respiratory alkylosis

 Manifestations
◦ Feeling of shortness of breath, increased rate and
depth of respiration. xerostomia
◦ Patient complain of light headedness and tingling
sensations around toes, fingers, and perioral region
◦ Chest pain, palpitations and tachycardia
◦ Muscle spasm, myalgia, tetany and tremors
 Terminate all dental treatments.
 Position the patient in almost fully upright

position
 Reassurance and anxiety reduction protocol
 Have patient to breath into co2 enriched air,

such as in and out of a small bag

 If symptoms worsen or persist, administer

diazapam10 mg or midazolam 5 mg IM or IV
slowly until patients calm down
ASTHMA
 Reparatory problems caused by drug allergy are difficult
to differentiate from asthmatic attack and their
management and manifestations are similar
 Manifestations of acute asthmatic attack
◦ Shortness of breath
◦ Wheezing is usually audible directly or with stethoscope
◦ dyspnea and tachycardia
◦ Coughing and anxiety
◦ In severe form
 Intense dyspnea, with flaring of nostrils and use of accessory muscle
of mastication
 Cyanosis of mucous membrane and nail beds
 Flushing, anxiety and confusion
 Minimal breath sounds on auscultation
 Management of respiratory problems
◦ Terminate all dental treatment
◦ Position the patient in fully sitting position
◦ Administer bronchodilator by spray
◦ Administer oxygen
◦ Monitor vital signs
◦ If signs and symptoms still continue
 Give epinephrine .3 ml of 1:1000 intravenously or
subcutaneously
 Start IV line and drip of crystalloid solution
(30liter/hour)
 Monitor vital signs
 If signs and symptoms still not relieved
◦ Call for medical assistance
◦ Start theophylline 250 mg IV given over 10 mints
and hydrocortisone 100mg IV or equivalent
◦ Prepare to transport for emergency care facility
Chronic obstructive pulmonary
disease(COPD)
 These patients depend on maintaining an
upright posture to breath adequately if in
spine position may lead to difficult breathing
 Have high co2 and low PO2 in their blood

which drive reparation. If given with high flow

oxygen they reparatory rate will fall and
cyanosis and apnea may follow
 If apnea occurs and patient losses

consciousness artificial ventilation may be

initiated and emergency assistance gained
Foreign body aspiration
 Small foreign objects aspirated may be
expelled out with violent coughing
 Large objects may obstruct the airway and

coughing is ineffective. Patient cant talk and

become extremely anxious. Cyanosis and loss
of consciousness follows
Management
 Position patient in sitting position
 Ask patient to try to cough out

Patient
Patient remains
become conscious
unconscious

Place the patient •Heimlich

in spine position maneuvers until
Abdominal thrusts effective
Attempt to •Administer oxygen
ventilate •Transport to
emergency
•Unable to ventilate
Able to ventilate •Abdominal thrusts
•Start BLS perform
•Administer laryngoscopy
oxygen and •Perform
transport to cricothyrotomy
emergency
Management of aspiration patient with
possible aspiration of gastric contents
 Place patient on right side in horizontal position and do
suction of the oropharynx
Once vomiting ceases and no
symptom of aspiration are present
Monitor vital signs for 30 mints
and if any suspicion of aspiration
is there than transport to
emergency care facility
Symptoms of aspiration are there
after vomiting
Start oxygen, seek medical
assistance, start crystalloid
solution at 150 ml/h
Monitor vital signs

Signs of hypoxia are there

•Perform endotracheal No signs of
intubation, pulmonary levage
•Administer theophylline 250
hypoxia
mg IV Transport to
•Start VLs and transport to emergency
Emergency
Thyroid storm (crisis)
 It is a sudden, sever exacerbation of
hyperthyroidism
 Precipitated by infection, surgery, trauma,

physiological or emotional stress

 Prone patient may have diagnosed

hyperthyroidism or have signs of

hyperthyroidism
Thyroid storm
 Manifestations
◦ Abdominal pain, cardiac dysrhythmias, palpitations,
tachycardia, tremor, hyperpyrexia, nervousness and
agitation
 Management
◦ Seek medical assistance and Administer oxygen
◦ Monitor vital signs and start BLS if necessary
◦ Start an IV line with a drip of crystalloid solution
◦ Transport patient to emergency care facility
Adrenal insufficiency crisis
 Main cause is adrenal insufficiency from
exogenous corticosteroid administration
 Primary adrenal insufficiency (Addison's disease)

or other medical conditions in which adrenal

cortex is destroyed are rare
 During stress adrenal cortex is not able to

release sufficient amount of gluco-

corticosteroids needed to meet the elevated
metabolic demands
 Manifestations
◦ Abdominal pain, confusion, feeling of extreme fatigue,
myalgia, weakness
◦ Hypotension and partial or complete loss of
consciousness
 Management
◦ Position in patient in supine position, with legs raised
and seek medical assistance
◦ Administer 100mg hydrocortisone or equivalent IM or IV
◦ Administer oxygen and start drip of crystalloid solution
◦ Monitor vital signs and access the need for BLS
◦ Transport to emergency