MEDICAL EMERGENCIES IN

DENTAL OFFICE

ATHIRA P R
I YEAR MDS
PMS COLLEGE OF DENTAL SCIENCE & RESEARCH
CONTENTS • INTRODUCTION
• CLASSIFICATION
• RISK FACTORS
• PREVENTION
• PREPARATION
• UNCONCIOUSNESS
• RESPIRATORY DISTRESS
• SEIZURES DRUG RELATED EMERGENCIES
• CHEST PAIN
• CARDIAC ARREST
• CONCLUSION
• REFERENCES
What is an Emergency Situation ??
 Common Emergency Situations are:
• Fainting (Vasovagal Syncope )
• Diabetic Coma
• Anaphylactic Shock
• Epileptic Seizures
• Cardiovascular Collapse (CVC)
• Thyroid Crises
• Adrenal Crises
• Asthmatic Attack
• Stroke (Cerebro-vascular
Accident, CVA)
Clinical Presentation of Emergencies

• Sudden loss of consciousness

• Chest pain & dyspnea
• Convulsions (fits)
MATSURRA 1990 – OCCURRENCE OF EMERGENCY SITUATIONS
TIME OF COMPLICATION % OF TOTAL

In waiting room 1.5

During or immediately 54.9%
following local anaesthesia
During treatment 22
After treatment (in office) 15.2
After leaving dental clinic 5.5
TREATMENT PERFORMED AT THE TIME OF COMPLICATION
MATSURRA 1990
TREATMENT % OF TOTAL
Tooth extraction 38.9
Pulp extripation 26.9
unknown 12.3
preparation 9
filling 7.3
incision 2.3
apicoectomy 0.7
Removal of fillling 0.7
alveoloplasties 0.3
 RISK FACTORS

Increased number of older patients

Longer appointments
Medical advances
Increased drug use
 CLASSIFICATION
NON CARDIOVASCULAR CARDIOVASCULAR
Stress related Stress related
 Vasodepressor syncope
 Angina pectoris
 Hyperventilation
 Seizure  Acute myocardial infarction
 Acute adrenal insufficiency  Acute heart failure
 Thyroid storm  Cerebral ischemia & infarction
 Asthma( bronchospasm)
Non stress related
Non stress related
 Orthostatic hypotension
 Acute myocardial infarction
 Overdose reaction  Sudden cardiac arrest
 Non stress related
 Hypoglycemia
 CLASSIFICATION
UNCONCIOUSNESS SEIZURES
• Vasodepressor syncope DRUG RELATED EMERGENCIES
• Orthostatic hypotension • Overdose
• Acute adrenal insufficiency • allergy
CHEST PAIN
RESPIRATORY DISTRESS
• Angina pectoris
• Airway obstruction • Acute myocardial infarction
• Hyperventilation SUDDEN CARDIAC ARREST
• Bronchospasm
• heart failure & acute pulmonary oedema
ALTERED CONCIOUSNESS
• Hyperglycemia – hypoglycemia
• Thyroid gland dysfunction
• Cerebrovascular accident
 Commonly occuring….
DATA FROM FAST T B, MARTIN MD, ELLIS T M JADA 1986
30,608 emergencies
 15,405- syncope (50%)
 2,583- allergic reaction
 2552- angina pectoris
 331- cardiac arrest
PREVENTION

• 90 % of medical emergencies can be prevented

• Remaining 10 % will occur inspite of all preventive
measures
• Prior knowledge of patient’s physical condition
enables incorporation of modifications in dental
treatment plan
To be forewarned is to be forearmed
• “Through effective implementation of stress reduction protocols
90% life threatening situations in dental office can be prevented”-
McCarthy 1971
• “10% of all nonaccidental deaths are classified as sudden
unexpected deaths….unpreventable”
 PREVENTION

• PHYSICAL EVALUATION
• PSYCHOLOGICAL EVALUATION
• DETERMINATION OF MEDICAL RISK
• MEDICAL CONSULTATION
• STRESS REDUCTION PROTOCOL
 Goals of physical evaluation
• Determine the patient’s ability to physically tolerate the
stress involved in the planned treatment
• Determine the patient’s ability to psychologically tolerate the
stress involved in the planned treatment
• Determine whether treatment modifications are required to
enable the patient to better tolerate the stress involved in the
planned treatment
• Determine whether the use of psychosedation is warranted
• Dentist must determine before treatment

The potential problem

The level of severity of problem
The potential effect on the planned treatment
 PHYSICAL EVALUATION

• Helps to determine the physical &

psychological status of the patient
• Identify the risk of the patient
• Seek medical consultation
• Instituite appropriate treatment modifications
 PHYSICAL EVALUATION involves
• Medical history
– questionnaire

• Physical examination
• Monitoring vital signs
– BP
– Heart rate
– Respiratory rate
– Temperature
– Weight
• Visual inspection of patient
• Function tests If indicated
 DETERMINATION OF MEDICAL RISK
ASA PHYSICAL STATUS CLASSIFICATION 1962
• ASA I – normal healthy patient without systemic disease
• ASA II- Mild systemic disease
• ASA III-severe systemic disease that limits activity but is not
incapaciating
• ASA IV-incapaciating systemic disease that is a constant threat to
life
• ASA V- morbid patient not expected to survive 24 hrs with or
without any operation
 ASA I
• Normal & healthy
• Medical history & physical evaluation indicate no abnormalities
• Organ & organ systems are in good health
• Physiologically able to tolerate whatever stress is associated with
their dental treatment without the risk of complications
Represents Green light for dental treatment
 ASA II
• Mild systemic disease or a healthy patient who demonstrates extreme
anxiety & fear in dental office
• Treatment modifications needed
• e.g.Type II diabetes (well controlled)
– Epilepsy, asthma, hyperthyroid or hypothyroid disease
– Healthy pregnant patient
– Allergy to drugs
– Extreme dental fears
– Healthy patients over 60 years
– BP 140-159 Hg (sy)or 90-94 mm Hg (di)
Severe systemic disease ASA III
• Do not exibit signs & symptoms of distress; however distress is exhibited when
patients encounter physiologic or psychologic stress
• Elective dental treatment is not contraindicated, but patients risk during treatment is
increased
• e.g. angina pectoris(stable)
– Post MI
– Post CVA
– Type I diabetes
– Heart failure
– COPD
– Hyperthyroid or hypothyroid disorders(symptomatic)
– BP 160-199 Hg (sy)or 95- 114 mm Hg (di)
• ASA I –no risk
• ASA II- have some risk, routine dental care is permitted provided
possible treatment modifications are made depending on the
medical condition
• ASA III- elective dental care is not contraindicated but patients
risk is increased
II & III yellow light patients– a warning to proceed but with caution
 ASA IV

• Incapaciating systemic disease that is a constant threat to their

lives
• e.g. unstable angina, MI within past 6 months
CVA within past 6 months
BP > 200 Hg (sy)or 115 mm Hg (di)
Severe HF or COPD
Uncontrolled type I DM
Uncontrolled epilepsy
• ASA IV-elective dental care should be postponed until the
patients medical condition has improved to at least an ASA III
• Red light – a warning that the risk involved in the treatment of
patient is too great to permit elective care
If a patient is not ASA Class I , the practitioner generally
has 4 options.
• Modify routine treatment plans by anxiety reduction
measures / pharmacological anxiety control techniques
• Obtain medical consultation for guidance in preparing
patient to undergo ambulatory oral surgery.
• Refusing to treat the patient in ambulatory setting
• Referring the patient to the physician
 MEDICAL CONSULTATION

• Medical consultation with the patient’s physician should be

considered in conditions in which dentist is uncertain about the
degree of risk.
• Consultation should be sought when the treating doctor is
uncertain about the nature of patient’s disorder or the possible
interactions between the disorder & the planned dental treatment

• Specific treatment modifications represent potentially important

steps the dentist must undertake to decrease the patients risk
• Medical consultation should not be obtained until dental &
physical evaluation is completed
• Discuss fully with the physician the proposed treatment plan &
the anticipated problems
• Advice of the physician should be carefully considered
• Consider steps to minimise any potential risk to the patient
• The risk cannot be shared with the physician
 STRESS REDUCTION PROTOCOLS
• A series of procedures that minimise dental treatment related stress
decreasing the degree of stress to which the patient is exposed
• Prevention or reduction of stress should start
– before the dental appointment
– continue throughout treatment and
– follow through into the post operative period if necessary
 STRESS REDUCTION PROTOCOLS
• Recognise the degree of patient’s medical risk & anxiety
• Complete medical consultation before dental therapy as needed
• Premedication
• Schedule the patient’s appointment in the morning
• Minimise the waiting time
• Consider psychosedation during surgery
• Monitor the vital signs
• Consider psychosedation if additional stress reduction is required
• Adequate pain control during treatment
• Do not subject medically compromised patients to long appointments
• Post operative control of pain & anxiety
 PREMEDICATION

• ORAL ADMINISTRATION OF SEDATIVE DRUGS- ↓

PREOPERATIVE STRESS
• Antianxiety or sedative- hypnotic drugs
– Alprazolam 4 mg
– Diazepam 2-10 mg
– Midazolam
• Administration of CNS depressant drugs 1 hr before the
procedure
• Anticipation of procedure can induce more stress than the actual
procedure itself
• Monitor vital signs pre & post opreatively
• Post treatment management is important
– Be available by phone 24 hrs a day
– Monitor pain control & prescribe antibiotics & analgesics
– Prescribe antianxiety drugs if the patient requires it
PREPARATION
TRY PREVENTING
AND
BE PREPARED
 PREPARATION

• Staff training
– Training programme for the dentist and assistants
• Office preparation
– Availability of emergency drugs and kits in dental office
 Morrow [1982] suggests appropriate level of
emergency training for the doctor and recommends
they have immediate access to emergency kits the
design of which is based on the distance between dental
office & nearest emergency medical facility
 TRAINING
• BLS [BASIC LIFE SUPPORT]
» CPR [ P A B C D ]

• ACLS [ ADVANCED CARDIAC LIFE

SUPPORT] CPR + ADVANCED DRUG ADMINISTRATION

• ATLS [ ADVANCED TRAUMA LIFE

SUPPORT]
 Basic Life Support

P→A→B→C→D
Check response

• Stimulate the victim by gently shaking

the shoulders & shouting the victims
name
• Lack of response establishes a
diagnosis of unconciousness
• Prompt management of
unconciousness from any cause
follows P→A→B→C→D
POSITIONING

• Summon assistance
• Victim is placed into supine position
with the brain at the same level as
heart and the feet elevated slightly
(10-15)
Assess & open airway

Head tilt + chin lift

• Rescuer places one hand on the victims forehead
applying a firm backward pressure with the palm
• Rescuer places the tips of two fingers (index &
middle) on the symphysis of mandible lifting the
mandible as the forehead is tilted backwards
Breathing
• Assessment of breathing & ventilation
• Rescuer leans over the victim placing his
ear 1 inch from the victim’s nose &
mouth so that any exhaled air can be felt
& heard
• Rescuer looks towards the chest of the
victim to see whether spontaneous
respiratory efforts are present
• Breathing is assessed for at least 5 sec &
not > 10 sec
Breathing
• In the absence of effective respiratory
movement rescue breathing is started
• Victim may receive artificial ventilation
by
• Exhaled air ventilation
• Mouth to mouth breathing
• Mouth to mask breathing
• Mouth to nose breathing
• Atmospheric air ventilation
• O2 enriched ventilation
 Exhaled air ventilation
• Rescuer delivers exhaled air to victims lungs
• Basic technique of artificial ventilation
MOUTH TO MOUTH
• Head tilt & chin lift is maintained
• With mouth wide open rescuer takes a deep
breath, makes a tight seal around victims
mouth & blows into the mouth

• The first cycle of ventilation consists of two full breaths

• Exhalation occurs passively when the rescuers mouth is
removed from the victim’s allowing gravity to deflate the lungs
• In adult – repeated once in every 5-6 sec(10-12 times per min)
• In infants- every 3 sec (20 times per min)
 MOUTH TO NOSE
Mask is held in position with hand
maintaining an airtight seal
Rescuers positions himself on the patient’s
side & mouth is placed on breathing port of
mask
Air is forced into victim until chest is seen
MOUTH TO NOSE to rise
 With one hand rescuer keeps the head of the victim tilted
backwards & the other hand lifts the victim’s mandible ,
sealing the lips
 Taking a deep breath rescuer then seals his lips around the
victims nose & blows until expansion of victims chest is felt
& seen
 Same rates
Atmospheric air ventilation

• Can deliver 21 % O2
• Devices which deliver atmospheric air to victims lungs
– Bag Valve Mask (BVM) devices such as Ambu bag &
pulmonary Manual Resuscitator
• Provide less ventilatory volume than mouth to mouth or mouth to
nose ventilation because of difficulty in maintaining an airtight seal
• Rescuer must be positioned near the top of victim’s head
– Airway adjuncts- oropharyngeal or nasopharyngeal
Oxygen enriched ventilation

• Source of 100% O2
• Portable O2 cylinder with an adjustable O2 flow and
a face mask
Adequacy of ventilatory efforts is assessed by
• Feeling the escape of air as victim passively exhales
• Seeing the rise & fall of victims chest
Circulation
a) Assess circulation
-monitoring of HR & BP
Sites- carotid artery, brachial & radial arteries
Carotid artery= most reliable indicator
 Carotid artery- located in a groove b/w
trachea & SCM – anterolateral aspect
 Fleshy portions of 1st & 2nd fingers are
used
 Carotid pulse palpated at least 5 sec &
not more than 10 sec
 Unless carotid pulse is present- external
chest compression is initiated
b) Activation of EMS
• EMS should be activated
c) Chest compressions

Rhythmic application of
pressure over lower half
of sternum
Chest compressions

• Location of compression point- lower half of sternum in the

middle of chest b/w nipples

• Depth of
compression- 4-5 cm
(1.5-2 inches)
• Rate of compressions-
100 per min
Chest compressions
Application of pressure
• Shoulders of rescuer directly over the
sternum of victim
• Elbows should be locked straight
Ventilation perfusion ratio
30:2 for single rescuer resuscitations
In an infant-
1/3 - ½ depth compressions
& 2 fingers used for compression
In a child –
1/3 - ½ depth compressions
& heel of hands used as for adults
Technique of chest compression

• Position yourself at victims side

• Make sure the victim is lying on his back on a firm flat surface
• Remove all clothing covering patients chest
• Place the heel of one hand on the centre of victims chest b/w nipples
• Put the heel of the other hand on the top of the first
• Straighten your arms and position your shoulders directly over your hands
• Push hard & fast. Press down 1.5-2 inches with each compression.
• At the end of compression make sure you allow the chest to recoil
completely
• Deliver compressions at the rate of 100 compressions per min
Definitive management

• Once patent airway has been provided & adequate

circulation ensured, proceed with definitive management
 DEFIBRILLATION

• BLS by itself doesnot provide the patient of an out of

hospital cardiac arrest when a significant chance of
survival
• Survival rates are less than 5 % P→A→B→C is
initiated promptly & efficiently but Defibrillation is delayed
more than 10 min
• But a 0% survival rate when BLS is not performed
 ACLS [ ADVANCED CARDIAC LIFE
SUPPORT]
ACLS training involves
• Adjunct for airway control & ventilation
• Patient monitoring & dysrhythmia recognition
• Defibrillation
• Cardiovascular pharmacology
• Acid base balance maintenance
• Venipuncture
• Resuscitation of infants , including newborns
 EMERGENCY DRUGS

 Drug administration is not

necessary for the immediate
management of medical
emergencies
 BLS is always used first.
 When in doubt, don’t
medicate
EMERGENCY DRUG KITS
Council of Dental Therapeutics of ADA
• Content & design of kit should be based on practitioner’s training
• Drugs to be included as a minimum
– Epinephrine 1:1000 (injectable)
– Histamine blocker (injectable)
– Oxygen with positive pressure administration capability
– Nitroglycerin(sublingula tablet or aerosol spray)
– Bronchodialator(inhaler)
– Sugar
– Aspirin
 EMERGENCY DRUGS

4 IMPORTANT CATEGORIES
 Basic emergency kit [critical drugs and equipment]
 Noncritical drugs and equipment
 ACLS drugs
 Antidotal drugs
 CRITICAL EMERGENCY DRUGS&
EQUIPMENT
• INJECTABLE DRUGS
• EPINEPHRINE
• HISTAMINE BLOCKER
• NONINJECTABLE DRUGS
• OXYGEN
• VASODIALATOR
• BRONCHODIALATOR
• ANTIHYPOGLYCEMIC
• INHIBITOR OF PLATELET AGGREGATION
• EQUIPMENT
• OXYGEN DELIVERY SYSTEM
• AUTOMATED ELECTRONIC DEFIBRILLATOR
• SYRINGES FOR DRUG ADMINISTRATION
• SUCTION & SUCTION TIPS
• TOURNIQUETS
 INJECTABLE DRUGS
EPINEPHRINE
HISTAMINE BLOCKER

EPINEPHRINE
 Most important emergency drug
 Properties—
 Rapid onset of action
 Potent action as bronchial smooth muscle dialator
 Histamine blocking properties
 Vasopressor actions
 Cardiac effects –↑ HR, ↑ sys BP, ↑ CO
 Indications- Dose – 0.3-0.5 ml IM or SC
 Anaphylaxis (1:1000 conc)
Kit should have 1 preloaded syringe
& 3-4 ampules of 1:1000 epinephrine
 Cardiac arrest (1:10000 conc)
 HISTAMINE BLOCKER
• Chlorpheniramine
• Diphenhydramine

 Properties—
 Competitive antagonists of histamine
 Indications-
 delayed onset allergic reactions
 As LA when patient has a history of allergy to LA
Emergency kit should contain 3-4 1 ml ampules of
Chlorpheniramine (10 mg/ml)
Diphenhydramine (50 mg/ml)
 NONINJECTABLE DRUGS

OXYGEN
• Most useful drug in the emergency kit
• Indications
– When respiratory distress is evident
• Available as compressed gas cylinders in
variety of sizes
– One E cylinder is a minimum requirement
for an emergency
VASODIALATOR

Nitroglycerine
Indications
chest pain- aid in the dd & management of angina pectoris,
early management of acute MI, acute hypertensive episodes
Available as 0.3,0.4,0.5mg sublingual tablets
0.4-0.8 mg/dose sublingual spray
BRONCHODIALATOR

• Albuterol
• Properties – have specific smooth muscle
relaxing properties with little or no action on CV & GI systems
• Indications
– Acute asthmatic episodes
– Allergic reactions with bronchospasm
• Available as inhalers
ANTIHYPOGLYCEMIC

• Orange juice
• Management of hypoglycemic state in a conscious patient

ANTIPLATELET DRUG
• Aspirin
• Indications – patients with suspected MI or unstable
angina
 CRITICAL EMERGENCY EQUIPMENT
OXYGEN DELIVERY SYSTEM
–positive pressure demand valve
–bag valve mask device
–pocket mask
• AUTOMATED ELECTRONIC DEFIBRILLATOR

• SYRINGES
–2-4, 2 ml disposable syringes with 18/21 guages

• SUCTION & SUCTION TIPS

–plastic evacuators & tonsil suction tips
• TOURNIQUETS
–Required when IV drugs are to be administered

• MAGILL INTUBATION FORCEPS

–aid in the placement of endotracheal tube during nasal
intubation
NON CRITICAL EMERGENCY DRUGS & EQUIPMENTS

• INJECTABLE DRUGS
• ANTICONVULSANT- Benzodiazepine (seizures)
• ANALGESIC – Morphine (intense pain: acute MI,
CCF)
• VASOPRESSOR – Phenylephrine (hypotension)
• ANTIHYPOGLYCEMIC – dextrose, glucagon
(unconcious patient)
• CORTICOSTEROID- hydrocortisone (acute allergy)
• ANTIHYPERTENSIVE- Esmolol, Propranalol (Acute
hypertensive episodes)
• ANTICHOLINERGIC - Atropine
NONINJECTABLE DRUGS
• RESPIRATORY STIMULANT
–Aromatic ammonia (respiratory
depression- vasodepressor syncope)

• ANTIHYPERTENSIVE
–Nifedipine (hypertension)
EQUIPMENTS
CRICOTHYROTOMY EQUIPMENT
ARTIFICIAL AIRWAY
EQUIP FOR ENDOTRAHEAL INTUBATION
 ACLS drugs

• EPINEPHRINE
• OXYGEN
• ANTIDYSRYHMIC- LIDOCAINE
• ANALGESIC- MORPHINE
• ATROPINE
• DOPAMINE
• VERAPAMIL
 ANTIDOTAL DRUGS

• OPIOD ANTAGONIST - Naloxone

• BENZODIAZEPINE ANTAGONIST- Flumazenil
• ANTIEMERGENCE DELIRIUM DRUG- Physostigmine
• VASODIALATOR- Procaine
 UNCONCIOUSNESS
RESPIRATORY DISTRESS
ALTERED CONCIOUSNESS
SEIZURES
DRUG RELATED EMERGENCIES
CHEST PAIN
SUDDEN CARDIAC ARREST
UNCONCIOUSNESS
Syncope & Faint
- transient loss of conciousness caused by reversible
disturbances in cerebral function
-only a symptom

Any loss of conciousness represents a potentially life

threatening situation requiring prompt recognition and
effective management
 causes
• Vaso-vagal syncope (faint)- most common
• Orthostatic hypotension
• Acute Hypoglycaemia
• Hyperventilation
• Epilepsy
• Anaphylactic shock
• Steroid crisis
• Myocardial Infarction
• Cardiac Arrest
• Cerebro vascular accident
Predisposing factors

• Stress
– Primary cause
• Impaired physical status
– ASA III & IV
• Administration or ingestion of drugs
– Analgesics , antianxiety drugs
 mechanisms – Engle 1962
• Reduced oxygen supply to the brain
• Vasodepressor syncope
• Orthostatic hypotension
• Acute adrenal insufficiency
• hypotension
• Reduced cerebral metabolism resulting from general or
local metabolic deficiencies
• Acute allergic reactions
• Sedatives, opioids
• Direct or reflex effects on CNS
• CVA
• Convulsive episodes
• Psychic mechanisms
• Vasodepressor syncope
• Hyperventilation
PREVENTION

• Pretreatment medical & psychological evaluation

• Stress reduction protocols
• Conscious sedation
• Supine position
MANAGEMENT

• Recognition of consciousness
– Assessment of consciousness
• Lack of response to sensory stimulation
• Loss of protective reflexes
• Inability to maintain a patent airway
– Termination of dental procedure
– Summoning help
Management
Position the victim – in supine position with feet elevated
Assess & open airway – head tilt & chin lift
Assess airway patency & breathing
Provide artificial ventilation if necessary
Assess circulation- carotid pulse for upto 10 sec
Provide circulation if necessary through chest
compression
Definitive management
 VASODEPRESSOR SYNCOPE

Most frequent emergency(53%)

Usually benign & self limiting process and if not managed correctly is
life threatening
 Syncope….
Sudden transient loss of conciousness
that usually occurs secondary to a period
of cerebral ischaemia
 Synonyms for syncope
• Atrial bradycardia
• Benign faint
• Neurogenic syncope
• Psychogenic syncope
• Simple faint
• Vasodepressor syncope
• Vasovagal syncope
 PREDISPOSING FACTORS

Psychogenic factors:- Non-psychogenic factors:-

• Fright • Erect sitting or standing
• Anxiety posture
• Emotional stress • Hunger from dieting or a
missed meal
• Receipt of unwelcome news • Exhaustion
• Pain, especially sudden and • Poor physical condition
unexpected pain • Hot, humid, crowded
• The sight of blood or surgical environment
or other dental instruments • Male gender
• Age between 16 and 35 years
PREVENTION

• Eliminate the predisposing factors

• Air conditioning the dental office
• insisting the patient to have their meals before dental
appointment
• Proper positioning- supine position
• Anxiety relief
• Conscious sedation
 PATHOPHYSIOLOGY
different stages of syncope:-

1. Presyncope
2. Syncope
3. Postsyncope (recovery)
 CLINICAL MANIFESTATIONS
PRESYNCOPE

Early Late
 feeling of warmth  Pupillary dialation
 Loss of color, pale or  Yawning
ashen-grey skin tone  Hyperpnea
 Heavy perspiration  Cold hands and feet
 Complaints of “feeling  hypotension
bad” or “feeling faint”  Visual disturbances
 Nausea  Dizziness
 Blood pressure at baseline  Loss of consciousness
level or slightly lower
 Tachycardia
SYNCOPE
• Loss of conciousness
• Breathing may become irregular or shallow
• Pupils dialate
• Convulsive movements- muscular twitching of hands, legs & facial
muscles
• Bradycardia continues, HR < 50/min
• Pulse becomes weak & thready
• Generalised muscular relaxation →airway obstruction, fecal
incontinence
Once patient is positioned in supine position, duration of syncope is
extremely brief ranging from several sec to sev min
POST SYNCOPE

• Return of consciousness
• Pallor, nausea, weakness, sweating may last for min – several hrs
• Confusion & disorientation
• Arterial BP begins to rise
• HR returns to normal
• Pulse becomes stronger
 PATHOPHYSIOLOGY

recipitated by a sudden decrease in blood flow to the brai

haracterised by
 a sudden drop in BP and
 A slowing in HR
PATHOPHYSIOLOGY
PRESYNCOPE

Stress causes release of ↑ amounts of catecholamines into circulation

↓ PR and ↑ blood flow to peripheral tissues
↓ in circulating blood volume
↓ arterial BP
↓ cerebral blood flow
Compensatory mechanism (Baroreceptor & chemoreceptor) activated
→ constriction of peripheral blood vessels, ↑ venous return and ↑ HR

If the situation is not managed → compensatory mechanism fatigue &

reflex bradycardia develops
HR < 50/min → significant ↓ in CO → cerebral ischaemia → loss of
conciousness
SYNCOPE
• Systolic BP may descend to as low as 20-30 mm Hg
• Convulsive movements – tonic clonic contractions
POSTSYNCOPE

• Hastened by placing the patient in supine position with legs

elevated slightly
• ↑ venous return to the heart & ↑ blood flow to the brain
• Weakness, sweating & pallor may persist for hrs
MANAGEMENT
PRESYNCOPE
Step 1:- POSITION
• As soon as the presyncopal signs and symptoms appear the
patient is placed in supine position.
• Muscle movement also helps increasing the return of blood from
the body periphery.
• If the patient can move his leg vigorously, the patient is less likely
to have peripheral pooling of blood, minimizing the severity of the
reaction.
Step 2:- A B C(AIRWAY-BREATHING-CIRCULATION)
• Oxygen may be administered through use of a full mask or an ammonia
ampule may be crushed under the patients nose to speed recovery.

Step3:- D(DEFINITIVE CARE)

• Determine the cause of the episode while the patient recovers.
• Modification in future dental treatment should be considered to minimise
the risk of reccurence.
• Planned treatment is proceeded only if both the doctor and the patient feel
that the treatment is appropriate, if either party remains doubtful,
treatment is postponed.
 MANAGEMENT SYNCOPE

Step 1:-(ASSESSMENT OF CONCIOUSNESS)

• The patient suffering from vasodepressor syncope demonstrates a lack of
response to sensory stimulation (“shake and shout”).
 SYNCOPE

Step 2:-(ACTIVATION OF DENTAL OFFICE EMERGENCY SYSTEM)

Step 3:-P(POSITION)
• The first and most important step in the management of syncope is the
placement of the victim in supine position.
• In addition slightly elevate the leg to increase the return of blood from
periphery.
• Failure to place the patient may lead to death of patient or permaenant
neurological damage secondary to prolonged cerebral ischemia with in 2 to 3
mins.
 SYNCOPE

Step 4:-A B C(AIRWAY-BREATHING-CIRCULATION)

(BASIC LIFE SUPPORT,AS NEEDED)
• In vasodepressor syncope, the head tilt-chin lift procedure successfully
establishes a patent airway.
• Assessment of airway patency and adequacy of breathing constitute the next
actions
• An adequate airway is present when the patient`s chest moves and exhaled
air can be heard and felt.
• Artificial ventilation may be some times necessary when spontaneous
breathing ceases.
• To assess circulation carotid pulse is palpated.
 Management of vasodepressor syncope
Assess consciousness
Active office emergency system
p-position patient supine with feet elevated slightly
A-B-C-Assess and open airway; assess airway patency and breathing ; assess circulation
D-initiate definitive care:
-Administer 02
-Monitor vital signs.
Perform additional procedures:
- Administer aromatic ammonia.
- Administer atropine if bradycardia persists.
-Maintain composure.
(postsyncopal recovery) (delayed recovery)
Postpone further dental activate emergency
treatment medical services.
Determine precipitating factors
 POSTURAL HYPOTENSION
ORTHOSTATIC HYPOTENSION
• 2ND leading cause of loss of consciousness
• Occurs when the patient assumes an upright position
• Is a result of failure of the baroreceptor reflex mediated increase in
peripheral vascular resistance in response to positional changes
• A drop in systolic BP of 30 mm Hg or greater or a 10 mm Hg or
greater fall in diastolic pressure that occurs during standing
 PREDISPOSING FACTORS

• Administration and ingestion of drugs

• Prolonged period of recumbency or convalesence
• Inadequate postural reflex
• Late-stage pregnancy
• Advanced age
• Venous defects in the legs
• Recovery from sympathectomy for “essential” hypertension
• Addison`s disease
• Physical exhaustion and starvation
• Chronic postural hypotension (Shy-Drager syndrome)
DRUGS AND DRUG CATEGORIES PRODUCING POSTURAL
HYPOTENSION

 ADRENERGIC NEURON BLOCKER

 ALPHA AND BETA ADRENERGIC BLOCKERS
 AMINODARONE
 ANGIOTENSIN-CONVERTING ENZYME INHIBITOR
 CENTRALLY ACTING ANTIHYPERTENSIVES
 CALCIUM CHANNEL BLOCKERS
 LEVODOPA
 VASODIALATORS
PATHOPHYSIOLOGY
• When patient changes from a supine to an upright
position , influence of gravity on CVS intensifies
• Blood pumped from heart must move upwards,
against gravity to reach cerebral circulation
• On the other hand with the patient in supine
position the force of gravity is distributed equally
over the entire body & blood flows readily from
heart to the brain
• Effect of gravity is such that Systolic BP decrease s by
2 mm for each 25 mm that the patients head is
situated above the level of heart
 CLINICAL MANIFESTATIONS

• No prodromal signs & symptoms

• BP ↓
• HR remains at baseline level or higher
• Exhibit all c/f of unconscious patient
• If unconsciousness persist for > 10 sec- may exhibit convulsive
movements
 CARDIOVASCULAR RESPONSE TO POSITIONAL CHANGES

Change (at 60 seconds postural

after sudden elevation normal hypotension

Systolic blood pressure baseline or decrease of

+or-10mmHg >25mmHg

Diastolic blood pressure increase of decrease of

10-20mmHg >10mmHg

Heart rate 5-20 beats per baseline or

minute above higher(>30 beats
baseline per minute

RAPID DECREASE IN BLOOD PRESSURE & NO CHANGE IN HR is

pathognomonic of postural hypotension
CLINICAL CRITERIA FOR POSTURAL HYPERTENSION

 Symptoms develop when individual stands.

 Standing pulse increases at least 30 beats per minute.
 Standing systolic blood pressure decreases at least 25 mm Hg.
 Standing diastolic pressure decreases at least 10mmHg.
 PREVENTION
• Medical history
• Physical examination
• Dental therapy considerations in
– Patients with h/o postural hypotension
– Patients receiving sedation during dental treatment
– Patients who have been reclined in dental chair for a long period
• Slowly reposition the patient
• Stand nearby as the patient stands after treatment
 MANAGEMENT
Step1:-Assessment of consciousness.
Step2:-Activation of the office emergency.
Step3:-P(Position)
In supine position with feet elevated slightly
Step4:-A-B-C (Airway-Breathing-Circulation).
Head tilt-chin lift procedure establishes the airway.
Look,listen,feel technique is used to detect any obstruction in
breathing.
Step5:-D(Definitive care)
administration of O2
monitoring of vital signs.
(Episode terminates): (Episode continues):
Provide subsequent management Summon medical assistance
Slowly reposition chair
 ADRENOCORTICAL INSUFFICIENCY
ADRENAL CRISIS

Uncommon
Potentially life threatening
Readily treatable
• Primary adrenocortical insufficiency
• Secondary adrenocortical insufficiency
Mechanism
1. After a sudden withdrawal of steroid hormone s in a patient who
suffers primary adrenal insufficiency
2. After a sudden withdrawal of steroid hormone s in a patient with
normal cortices but with a temporary insufficiency resulting from
cortical suppression through prolonged exogenous corticosteroid
administration (secondary insufficiency)
3. After stress – physiologic or psychologic
4. After bilateral adrenalectomy
5. After sudden destruction of pituitary gland
6. After both adrenal glands are injured through trauma, hemorrhage,
infection
 acute adrenal crisis
CAUSES:
ADDISONS DISEASE
• Stress Conditions, psychological stress
• Surgical/Other trauma
• Infection
SIGNS & SYMPTOMS
• Pallor
• Weakness
• Nausea, vomiting
• Rapid, weak or impalpable pulse
• Loss of consciousness
• Rapidly falling BP
PREVENTION

• Medical history, drug history

• Medical consultation
• Dental therapy considerations
– Patients who are currently receiving steroid therapy or have
recently received such therapy & meet the criteria of rule of
twos require dental treatment modifications
– Gluococorticosteroid coverage- may require a 2 fold or 4 fold
↑ in the dose on the day of dental treatment
– Stress reduction protocol
 Rule of twos
• Adrenocortical suppression should be suspected if a patient has
received glucocorticosteroid therapy
• In a dose of 20 mg or more of cortisone or its equivalent
• Via oral or parenteral route for a continuous period of 2 weeks or
longer
• Within 2 years of dental therapy
 MANAGEMENT
• Terminate dental treatment
• Position : supine with legs slightly elevated
• A- B- C
• Definitive care
» vital signs
» Summon medical assistance
» Give oxygen
» Administration of glucocorticosteroid
» Hydrocortisone 100mg i.v.
• Additional management
» IV Infusion 1 L normal saline or 5 % dextrose over 1 hour
• Transfer to hospital
RESPIRATORY DISTRESS
 RESPIRATORY DISTRESS
caused by the difficulty breathing.
• seen in almost all medical emergencies.
• The primary cause of airway obstruction is mechancal; the tongue
falls into the hypopharnx as skeletal muscle tone is lost.
• There are two steps of basic life support
A-Airway
B-Breathing
-are designed to eliminate this problem.
 POTENTIAL CAUSES
 Hyperventilation
 Vasodepressor syncope
 Asthma
 Heart failure
 Hypoglycemia
 Over dose reaction
 Acute myocardial infraction
 Anaphylaxis
 Angioneurotic oedema
 Cerebrovascular accidents
 Epilepsy
 hyperglycemic reaction
• Patient usually exhibits respiratory distress when an
underlying medical disorder gets exacerbated
• A major factor leading to exacerbation of respiratory
disorders is stress
 Sites of origin of respiratory distress

• Bronchioles- asthma
• Cerebral cortex- hyperventilation
• Larynx- acute airway obstruction
• Heart & lungs- pulmonary oedema
MANAGEMENT
Recognize respiratory distress-(sounds- wheezing, cough ,crackling
abnormal rate or depth of respiration

Terminal dental procedure.

P-position patient supine, if unconscious,

Or comfortably if conscious

A-B-C- Assess and provide basic life support,as needed.

D-Monitor vital signs-blood pressure,heart rate(pulse),

Respiratory rate.
Manage patient anxiety.
Provide definitive management of respiratory distress(manage the cause of respiratory
distress)
 COMMON CAUSES

• FOEIGN BODY OBSTRUCTION

• HYPERVENTILATION
• ASTHMA
• PULMONARY OEDEMA
FOREIGN BODY AIRWAY 0BSTRUCTION

 During dental treatment the potential is great that objects may

fall into the posterior portion of the oral cavity and subsequently
in the pharynx
 The introduction of sit down dentistry in which patient is placed
in a supine or semisupine position has increased the likelihood
of such an incident
• When swallowed- usually pass completely through GIT
• In some cases complications- GI blockage, peritoneal abscess,
perforation…..
• When aspirated- enter larynx 7 may rest in a part of bronchi
• Complications- infection, lung abcess, pmeumonia
 INSTRUMENTS AND TECHNIQUES USED TO PREVENT
ASPIRATION AND SWALLOWING OF OBJECTS
 Rubber dam
 Oral packing
 Chair position
 Dental assistant
 Suction
 Majill intubation forceps
 Ligature
 MANAGEMENT - VISIBLE OBJECTS
Place patient in supine position or Trendelenburg position.

Use Majill’s intubation forceps or suction

Placing the patient inTrendelenburg position allows gravity to move the object
closer to oral cavity where it may be visible, aiding in retrieval with Majill’s
intubation forceps

OR
Instruct patient to bend over arm of chair with head down.

Encourage patient to cough.

MANAGEMENT – IF THE OBJECT IS NOT VISIBLE
…..SWALLOWED OBJECTS

Consult radiologist

Obtain appropriate radiographs to determine location of object.

If the foreign object is located within the GI or respiratory tract-

Initiate medical consultation with appropriate specialist
 Signs & symptoms – aspiration
• Sudden onset of coughing
• Choking
• Wheezing
• Shortness of breath
 Signs of complete airway obstruction

 Inability to speak.
 Inability to breath.
 Inability to cough.
 Universal sign for choking.
 Panic.
 Management of aspirated objects
Place patient in left lateral decubitus position with the head down

Encourage patient to cough.

Object is retrieved. Object is not retrieved .

Initiate medical consultation consult with radiologist or

before discharge emergency department.
obtain appropriate radiographs
to determine location of object.

Perform bronchoscopy to
visualize and retrieve object.
 Establishing an emergency airway
• Non invasive procedures
• Back blows
• Manual thrust
• Abdominal thrust (Heimlich maneuver)
• Chest thrust
• Finger sweep
• Invasive procedures – require surgical intervention & considerable knowledge &
technical skill
• Tracheostomy
• cricothyrotomy
• Back blows-back slaps – obstructive airway management in an
infant
Manual thrusts- a series of thrusts to
the upper abdomen
((Heimlich maneuver or abdominal
thrust) or to the lower chest
(chest thrust)
produce a rapid increase in
intrathoracic pressure acting as an
artificial cough that helps to dislodge
a foreign body
• Finger sweeps- place the index finger along the inside of victims
cheek & advance it deeply into pharynx at the base of tongue.
Using a hooking movement foreign body is tried to get dislodged
• A CONSCIOUS VICTIM
ask the victim to talk.
• If talk is possible, the airway is not completely obstructed and it is
best to leave the victim alone until he can dislodge the food or
object himself by coughing, throat-clearing, or with his fingers.
• If the victim cannot talk, the airway is completely obstructed-
should assist in dislodging the obstruction.
• The technique recommended by the American Heart Association
is a series of abdominal thrusts known as the Heimlich maneuver.
ABDOMINAL THRUSTS, OR HEIMLICH MANEUVER (5-6 SECONDS)

The victim should be sitting or standing. Grasp the

victim from behind with your hands around his
waist.
2. Make a fist with one hand and place the thumb
side on the victim's abdomen, midway between the
waist and the rib cage. Grasp the fist with your
other hand and thrust forcefully inward and upward.
Each new thrust should be a separate and distinct
movement .
CHEST THRUSTS (5-6 SECONDS)

If the victim is pregnant or especially obese, it is safer and easier to

do a chest thrust rather than an abdominal maneuver. The same two-
fist technique is used, but the victim is grasped at the breastbone
instead of the abdomen
 IN AN UNCONSCIOUS VICTIM

1. ABDOMINAL THRUSTS (5-6 SECONDS)

1. Kneeling next to or astride the victim, place the heel of one hand
on the abdomen midway between the waist and the rib cage.
2. Place the other hand on top of the first (as you would for chest
compressions, but on the abdomen rather than the chest) and thrust
inward and upward. Give several quick thrusts
2. CHEST THRUSTS (5-6 SECONDS)
3. FINGER SWEEP (6-8 SECONDS)
Recommended sequence for removing air way obstruction
 For adult conscious victim with obstructed air way

Identify complete air way obstruction: ask “are you choking?”

Apply the Heimlich maneuver until foreign body is expelled or the victim becomes
unconscious.

Have medical or paramedical personnel evaluate patient for complication before

dismissal.
For adult conscious with known obstructed airway,who loss consciousness
Place patient in supine position with head in neutral position; call for help.

Activate the EMS system if a second person is available.

Open the victim’s mouth using tongue-jaw lift.

Perform finger sweep.

Attempt to ventilate the patient ; if ineffective.

Perform 6 to 10 abdominal thrusts

Check for foreign body with finger sweep.

Attempt to ventilate the patient ; if ineffective.

Repeat abdominal thrust , finger sweep , and attempted ventilations until effective.

Have medical or paramedical personnel evaluation patient for complications before

dismissal.
 For adult unconscious victim, cause unknown
Rescuer manages unconscious victim in usual manner:
assess unresponsiveness.

P-Position victim in supine position with feet elevated.

Call for help(office emergency team).

A- Open airway(head tilt-chin lift)

B- assess breathing (look, listen, feel), and

attempt to ventilate. If unsuccessful,

Activate EMS system and

 Perform Heilmlich maneuver:6 to 10 abdominal thrusts.

Perform foreign body check: finger sweep.

Attempt to ventilate ; if ineffective,

Repeat Heimlich maneuver , finger sweeps and ventilation, until successful

 HYPERVENTILATION
defined as ventilation in excess of that required to maintain
normal blood PaO2 (arterial oxygen [O2] tension) and PaCO2
(arterial carbon dioxide[CO2] tension).
• It is one of the most common emergency situation that occur
in dental office due to extreme anxiety.
• Organic causes for hyperventilation also exist these include
pain, metabolic acidosis, drug
intoxication,hypercapnea,cirrhosis, and organic central nervous
system disorder.
• The patient complaints of feeling faint, light headed, or both
but does not loss conciousness.
 Clinical manifestations of hyperventilation

SYSTEM SIGNS AND SYMPTOMS

Cardiovascular palpitation, tachycardia,precordial

pain.

Neurologic dizziness,light headedness,

disturbances of cosciousness or
vision,numbness,and tingling of
extremities, tetany(rare).

Respiratory shortness of breath, chestpain,

dryness of mouth.

Gastrointestinal Globus histericus, Epigastric pain.

Musculoskeletal muscle pain and cramps, tremor,

stiffness,Carpopedel tetany.

Psychologic Tension, anxiety,nightmares.

 Management of hyperventilation
Terminate dental procedure

P- Position patient comfortably (upright)

A-B-C- basic life support, as needed

D- definitive care:
Remove dental materials from patients mouth
Calm patient
Correct respiratory alkalosis
Initiate drug management, if necessary

Perform subsequent dental treatment

ASTHMA
 Causative factor of asthma

 Allergy (antigen-antibody reaction)

 Respiratory infection
 Physical exertion
 Environmental and air polution
 Occupational stimuli
 Pharmacogenic stimuli
 Psychologic factor
 Signs and symptoms of acute asthma
 Feeling of chest congestion.
 Cough with or without sputum production.
 Wheezing
 Dyspnea
 Patient wants to sit or stand up.
 Use of accessary muscles of respiration.
 Increase anxiety and apprehension.
 Tachypnea (>20 to >40 breath per minute in several cases)
 Rise in blood pressure.
 Increase in heart rate(>120 beat per minute in several episodes)
 Diaphoresis.
 Agitation.
 Somnolence.
 Confusion.
 Cyanosis.
 Supraclavicular and intercostal retraction.
MANAGEMENT
Termination of dental procedure
Reassure the patient
Position the patient comfortably
A-B-C
Definitive management-
Give the anti asthmatic drug normally used
Give oxygen
Give Adrenaline
Hydrocortisone 200 mg i.v.
Monitor VS
CALL AN AMBULANCE
ALTERED CONSCIOUSNESS
 Acute Hypoglycaemia

Most common dental complication seen in diabetic patients taking

insulin
Blood glucose levels below 60 mg/dl

CAUSES:
• Overdose of insulin
• Prevented from eating at expected time
Factors that causes hypoglycemia
• Weight loss
• Increased physical exercise
• Termination of pregnancy
• Termination of other drug therapies
for example:- epinephrine, thyroid,or corticosteroids.
• Recovery from infection and fever
 Signs & symptoms

• Shakiness & tremors

• Confusion
• Agitation & anxiety
• Sweating
• Tachycardia
• Dizziness
• Feeling of impending doom
• Unconciousness
• Seizures
Management of Hypoglycemia – conscious patient
step 1:-recognition of hypoglycemia
Step2:-termination of hypoglycemia
Step3:-P-Position:place the patient upright.
Step4:-A-B-C- assess and perform BLS if needed
Step5:-D-definitive care
Step5a:-administration of oral carbohydrate
Step5b:-summoning of medical assistance
Step5c:-administration of parenteral carbohydrates
Step5d:-monitoring of patient
Step6:-discharge and subsequent dental treatment
Hypoglycemia –unconscious patient

Step1:-termination of dental procedure

Step2:-position. In supine position.
Step3:-A-B-C (BLS if need)
Step4:-definitive care
Step4a:-summoning of medical assistance
Step4b:-administration of carbohydrate
Step5:-recovery and discharge
• Provide 15 g oral carbohydrate to the patient
» 4-6 oz of juice
» 3-4 tsp of table sugar
» Hard candy with 15 g sugar

• If the patient is unable to take food or drink by

mouth / if the patient is sedated
» Give 25-30 ml of 50 % dextrose IV
» 1mg glucagon IV (SC/ IM if no IV access)
Factors that cause hyperglycemia
• Weight gain
• Cessation of exercise
• Pregnancy
• Hyperthyroidism or thyroid medication
• Epinephrine therapy
• Corticosteroid therapy
• Acute infection
• Fever
 Management of hyperglycemic-unconcious patient
Terminate dental procedure

P-position patient supine with legs elevated slightly

A-B-C-Assess and perform BLS, as needed.

D-initiate definitive care:

Summon emergency medical assistance
Establish IV infusion , if possible
Administer oxygen
Transport patient to hospital for further management
Hypoglycaemia Hyperglycaemia

• Rapid onset • Slow onset

• Irritability • Drowsiness/disorientation
• Dry skin & mouth
• Moist skin
• Pulse slow & weak
• Pulse full & rapid • Rare
• More common • More Severe
• Less Severe • Difficult to be managed
• Easy to be managed
 THYROID CRISIS (STORM)

• Sudden, Severe Exacerbation of Hyperthyroidism

Precipitating Factors:
• Infection
• Surgery
• Trauma
• Pregnancy
• Other Physiologic or Emotional Stress
Manifestations:
• Hyperpyrexia (Fever)
• Sweating, heat intolerance
• Exophthalomos
• Tremor
• Tachycardia
• Agitation
• Palpitation
• Nausia, Vomiting
• Abdominal pain
• Loss of Consciousness (Partial or Complete)
Management:
• Terminate all dental treatment
• Position- patient placed in supine position with leg elevated
• Summon medical assistance
• Initiate BLS, if necessary
• Start IV line & Fluids
• AdministerO2
• Monitor VS
• Transport to ER Care
 STROKE (CVA)

Predisposing factors
• high BP
• Diabetes mellitus
• Cigarette smoking
• Use of OCP
• hypercholestrolemia
In Cerebrovascular accident patients intravascular hemorrhage more
common in dental office.
 sudden onset of headache
 Vomitting
 ↑BP
 focal neurologic signs and symptoms
 Chills
 Dizziness
 vertigo
 loss of consciousness
 MANAGEMENT
Discontine the dental procedure
Position: Semi Fowler ( almost supine with head and chest elevated
slightly, will ↓ intra cerebral blood pressure)
ABC
Definitive management- monitor vital signs
Administer O2
Sedatives not given as neurological signs will be masked
Patient will recover in office if Transient Ischemic Attack
SEIZURES.
 SEIZURES.

Witnessing a seizure is a traumatic experience for most individuals.

Most convulsive episodes are simply transient alteration in brain
function characterized clinically by an abrupt onset of motor,
sensory or psychic symptoms.
In these instances, the prevention of injury to the victim during
the seizure and supportive therapy after the episode constitute the
essentials of management.
Causes for seizures in dental office

Seizure in an epileptic patient

Hypoglycemia
Hypoxia secondary to syncope
Local anaesthetic overdose
Factors sometimes precipitating seizures in
susceptible subjects

• Withdrawal of anticonvulsant
medication.
• Some drugs.
• Stress
• Fatigue, starvation
• Infection
• Menstruation
• Flickering lights
Diagnostic clues for the presence of petit-mal or
partial seizure

1) Sudden onset of immobility and

blank stare.
2) Simple automatic behavior.
3) Slow blinking of eyelids.
4) Short duration (seconds to
minutes) average (1-2 min)
5) Rapid recovery.
Management of petit mal & partial seizures

Terminate dental procedure

Position ---supine position with feet elevated

Seizure ceases;
Seizure continues (more than 5 min);
Reassure the patient.
Call for medical assistance.

Allow the patient to recover

before discharge. A-B-C- perform BLS, as needed.
 Generalized tonic – clonic seizures (grand mal)

Diagnostic clues that a prompt suspicion of GTCS are as follows

1) Presence of aura prior to loss of consciousness.
2) Loss of consciousness.
3) Tonic clonic muscle contraction.
4) Clenched teeth; tongue biting.
5) Incontinence.
Management grand mal seizures

Prodromal stage
(Terminate dental procedure)

Ictal stage
Position; Position the patient supine with the legs elevated slightly.

Call for emergency medical assistance.

A-B-C; Assess and perform BLS, as needed.

D – Definitive care protect patient from injury

Administer oxygen
Monitor vital signs.
 Postictal stage
Position -- keep patient supine with feet elevated.

A-B-C --Perform BLS as needed

D -- Definitive care

Monitor vital signs

Reassure patient and permit recovery

Discharge patient

To hospital To home To physician

Drug related emergencies.
 Drug overdose reactions
 Allergy
The administration of drugs
• Local anesthetics
• Analgesics
• Antibiotics
• Anti anxiety drugs

These four drug categories constitute the majority of all drugs

used in the practice of dentistry.
Approximately 85% of ADRs result from the pharmacologic
effects of the drugs, whereas 15% result from immunologic
reactions.
Several potential responses to drugs exist that are life threatening
and require immediate effective management
Such responses include the overdose reaction and the allergic
reactions.
 Drugs commonly used in dentistry and their most common
ADRs.
DRUGS ALLERGIES OVERDOSE SIDE EFFECTS

Local Common, especially Unlikely with esters Rare; Sedation

Anesthetics with topical unless genetic (drowsiness)
Esters Anesthetics: manifested deficiency is present
as localized erythema (e.g. Atypical most common.
and edema. pseudocholin
esterase).

Amides Rare; Virtually non – Most common ADR; Rare; sedation

existent: most clinical CNS depression;
reports prove alleged manifested as most common.
allergy to be overdose drowsiness; tremor,
or allergy to other
component of solution. tonic-colonic seizures.
Drugs commonly used in dentistry and
their most common ADRs
DRUGS ALLERGIES OVERDOSE SIDE
EFFEC
TS

Antibiotics Common; high Rare; virtually non- Rare; GI

allergic potential to existent with upset
many antibiotics; penicillin. most
manifested clinically common.
over entire range of
allergic phenomena.
 Drugs commonly used in dentistry and
their most common ADRs.

DRUGS ALLERGIES OVERDOSE SIDE EFFECTS

Analgesics Common; high Common; Common.

Nonopioid allergic potential Salicylism.
(aspirin)

Uncommon. Common; Most common

Opioid Manifested as CNS ADR; manifested
depression clinically as nausea
(drowsiness) or or vomiting,
respiratory orthostatic
depression. hypotension.
Drugs commonly used in dentistry and
their most common ADRs.
DRUGS ALLERGIES OVERDOSE SIDE EFFECTS

Anti anxiety Uncommon Most common ADR; Common;

Agents. CNS depression; barbiturate hang
Barbiturates. manifested as over over.
sedation, loss of
consciousness,
respiratory and
cardio vascular
depression.
Benzodiazepines. Uncommon Uncommon; CNS Drowsiness most
depression; Common.
Manifested as over
Sedation.
Nitrous oxide. Rare; Never Common; Most common
reported to manifested as Over ADR; Manifested
date. sedation. as Nausea or
vomiting.
 Over dose reaction ( Toxic reaction):
 Those clinical signs and symptoms resulting from an absolute or a
relative over administration of drug that leads to elevated blood
levels of the drug in various target organs and tissues
 Most common of ADRs- 85%
 For an overdose to occur the drug must gain access to the body’s
circulation in sufficient quantities to produce adverse effects in the
target organs
 e.g.. Barbiturate overdose (higher blood levels of the barbiturate
in the CNS) produces a more profound CNS depression, increasing
the possibility of respiratory and cardiovascular depression
 drug categories
• Local anesthetics –most used
– Overdose Manifests as generalised tonic clonic seizures or
unconsciousness
• Vasoconstrictorsd(norepinephrine)- anxiety reaction accompanied
by ↑ BP & HR
• Sedative hypnotics – CNS and respiratory depression
• Opioid analgesics- CNS and respiratory depression
 Drug Overdose Reactions
Predisposing factors for drug overdose.
1. Patient factors
- Age (Under 6 Years; over 65 Years)
- Body weight (Lower body weight increasing risk)
- Pathologic processes (liver disease, congestive heart
failure, pulmonary disease)
- Genetics (for example, atypical plasma cholinesterase)
- Mental attitude (anxiety decreasing seizure threshold)
- Sex (slight increase in risk during pregnancy)
Drug factors:
- Vasoactivity (vasodilatation increasing risk)
- Dose (higher does increasing risk)
- Lipid solubility & plasma protein binding (decreases
systemic absorption)
- Route of administration (intravascular route increasing risk)
- Rate of Injection (rapid injection increasing risk)
- Vascularity of injection site (increased Vascularity increasing
risk)
- Presence of vasoconstrictor (decreasing risk).
LOCAL ANESTHETIC OVERDOSE
Causes of high blood levels of local anesthetics

 Biotransformation of the drug is

unusually slow.
 Drug is slowly eliminated from the body
through the kidneys.
 Total dose of local anesthetic
administered is too large
 Absorption of LA from the site of
injection is unusually rapid
 Local anesthetic is inadvertently
administered intravascularly.
Clinical manifestations of local anesthetic overdose
Low to moderate overdose levels: initial signs excitatory
 Confusion
 Talkativeness
 Apprehension
 Excited ness
 Slurred Speech
 Generalized Stutter
 Muscular twitching and tremor of the face and extremities
 Nystagmus
 Elevated blood pressure
 Elevated heart rate
 Elevated respiratory rate
 Clinical manifestations of local anesthetic
overdose

Moderate to high blood levels:

 Generalized tonic clonic seizures followed by
 Generalized CNS depression
 Depressed blood pressure, heart, rate, and
respiratory rate
 Symptoms
 Headache.
 Lightheadedness.
 Dizziness.
 Blurred vision, inability to focus.
 Ringing in ears.
 Numbness of tongue and perioral tissues.
 Flushed or chilled feeling.
 Drowsiness.
 Disorientation.
 Loss of consciousness.
Local anesthetic blood levels & actions on
CNS & CVS
CNS
• 0.5-4 µg/ml- anticunvulsant
actions
• 4.5-7 µg/ml- CNS depression
manifest as excitation
• 7.5-10 µg/ml- CNS depression
manifest as tonic clonic seizures
• 10 µg/ml +
CVS
• 1.8-5 µg/ml – Antidysrhythmic
actions
• 5-10 µg/ml - ECG alterations-
Myocardial depression,
peripheral vasodialation
• 10 µg/ml + massive peripheral
vasodialation, intense
myocardial depression, cardiac
arrest
Management of local anesthetic overdose
Recognise the problem- onset 5-10 min after LA
administratiomnn, talkativeness, increased anxiety, facial muscle
twitching, ↑ HR & RR
Terminate dental procedure

P – Position patient comfortably

Reassure patient

A-B-C – Assess an perform BLS, as needed

D – Initiate definitive care:

Administer 02.
Monitor vital signs.
Administer anticonvulsant drug[DIAZEPAM 2.5-5 mg/
MIDAZOLAM], if needed.
call for emergency medical assistance.
Permit recovery and discharge patient.
Epinephrine (Vasoconstrictor) Overdose Reaction

Vasoconstrictors commonly used in dentistry.

AGENT AVAILBLE MAXIMUM DOSE

CONCENTRATIONS

Epinephrine. 1:50,000 Healthy adult : 0.2 mg.

1:100,000 Cardiac patient : 0.04

mg.
1:200,000

Levonordefrin. 1:20,000 Healthy adult : 1.00mg

Cardiac patient : 0.2mg
 Clinical manifestations of epinephrine overdose – similar
to acute anxiety response
Signs
Elevated blood pressure-may produce potential hazards- cerebral hemorrhage,
cardiac dysrhythmias
Elevated heart rate.
Symptoms
Fear. Perspiration .
Anxiety. Weakness.
Tenseness. Dizziness.
Restlessness. Pallor.
Throbbing headache.
Respiratory difficulty.
Tremor.
Palpitations.
Management of an epinephrine (vasopressor) overdose

Terminate dental procedure

P – Position patient comfortably

A-B-C – Assess and perform BLS, as needed

D – Initiate definitive care:

Reassure patient
Monitor vital signs
call for medical assistance
Administer 02
Permit recovery
Administer vasodilator- nitroglycerine (optional)

Permit recovery and discharge patient.

Diagnostic clues to an overdose of a sedative
hypnotic drug

 Recent administration of sedative-

hypnotic drug.
 Decreased level of consciousness.
 Sleepy / unconscious.
 Respiratory depression ( rapid rate,
shallow, depth)
 Loss of motor coordination (ataxia)
 Slurred speech
Management of Sedative - Hypnotic Drugs
Terminate dental procedure
P – position patient comfortably
A-B-C – assess and perform BLS, as needed
D – initiate definitive care:
Call for medical assistance, if required
Administer 02
Monitor vital signs
Establish IV line, if possible
Provide definitive management
Administer intravenous or IM flumazenil (IV)
for benzodiazepine overdose.
Continue P-A-B-C for barbiturate
overdose.
Permit recovery and discharge patient.
 Diagnostic clues of an Opioid overdose

 Altered level of consciousness.

 Respiratory depression (slow rate: normal to
deep depth)
 Miosis (contraction of pupils of the eyes)
Management of opioid overdose
Terminate dental procedure

P – position patient supine with the legs

elevated slightly

A-B-C – Assess and perform BLS, as needed

D – Initiate definitive care:

Call for medical assistance, if required
Administer 02
Monitor and record vital signs
Establish IV line, if possible
Administer antidotal drug (intravenous or IM naloxone)

Permit recovery and discharge patient.

211
 Allergy:
defined as a hypersensitive response
to an allergen to which the individual
has previously exposed and to which
that individual has developed
antibodies.

(overdose reactions are dose related.

Allergy , in contrast, is not dose
dependent.)
Allergic reactions cover a broad range of clinical manifestations,
from mild, delayed reactions that develop as long as 48 hours
after exposure to the antigen, to immediate and life – threatening
reactions developing within seconds of exposure.

213
2 forms of allergy are particularly important in dentistry
• Type I – ANAPHYLAXIS
• Type II- delayed hypersensitivity- contact dermatitis
TYPE MECHANISM PRINCIPAL TIME OF CLINICAL
ANTIBODY REACTIONS EXAMPLES

Anaphylactic Anaphylaxis
(immediate, (drugs, insect
I antigen induced, Seconds to venom, antisera)
antibody minutes Atopic.
IgE
mediated). Rhinitis.
Urticaria.
Angioedema.
Hay fever.

215
TYPE MECHANISM PRINCIPAL TIME OF CLINICAL
ANTIBODY REACTIONS EXAMPLES

IgG Transfusion
IgM reactions.
II. Cytotoxic. (activate Autoimmune
hemolysis.
complement) ---
Hemolytic anemia.
Certain drug
reactions.
Systemic lupus
Erythematous.

216
TYPE MECHANISM PRINCIPAL TIME OF CLINICAL
ANTIBODY REACTIONS EXAMPLES

III. Immune IgG 6 - 8 hours Membranous

complex (Anti glomerulonephrits
body mediated) .
Serum sickness.
Lupus nephritis.
Occupational
allergic alveolitis.
Acute Viral
hepatitis .

217
TYPE MECHANISM PRINCIPAL TIME OF CLINICAL
ANTIBODY REACTIONS EXAMPLES

IV. Cell – mediated 48 Hours Allergic contact

(delayed ) or - dermatitis.
tuberculin – Infectious
type response. Granulomas.
Tissue graft
Rejection.
Chronic
hepatitis.

218
 The more commonly used drugs in dental practice
that possess significant potential for allergy.
Antibiotics
Penicillines.
Cephalosporins.
Tetracyclines.
Sulfonamides.
Analgesics
Acetylsalicylic acid (aspirin)
NSAIDs
Opioids
Morphine.
Meperidine.
Codeine.

219
 The more commonly used drugs in dental practice
that possess significant potential for allergy.
Antianxiety drugs
Barbiturates.
Local anesthetics
Esters
procaine.
propoxycaine.
Benzocaine.
Tetracaine.
Antioxidant
Sodium (meta) bisulfate.
Parabens
Methylparaben.
Other agents
Acrylic monomer ( methyl methacrylate)
Latex 220
DENTAL THERAPY MODIFICATIONS

• When a patient is proved to be truly allergic to a drug,

precautions must be taken to prevent the individual from
receiving that substance.
• Inside the chart it should be noted – the patient is allergic to
• For all of the more highly allergenic drugs prescribed in
dentistry, substitute drugs are available that are usually
equipotent in therapeutic effect but that pose less of a risk of
allergy.
• Penicillin allergy may be circumvented through the use of
erythromycin

221
• Acetaminophen is the drug employed in cases
of allergy to aspirin.

• Allergy to opioid analgesics is rare, However,

in the presence of true opioid allergy, no
opioid should be used because cross –
allergenicity occurs.

• Nonopioid analgesics may be used in those

situations.
222
• Barbiturate allergy represents an absolute contraindication to the use
of any barbiturate because cross – allergenicity exists among all group
members.
• Drugs like benzodiazepines are used e.g.: flurazepam, diazepam,
midazolam, oxazepam, and triazolam, as well as chloral hydrate, and
hydroxyzine.

• Allergy to methyl methacrylate monomer is most readily avoided by

not employing acrylic resins. If, however, acrylic resins must be used,
heat-cured acrylic is much less allergenic than cold-cured or self cured
acrylic.

223
• Another potential cause of allergy involves the (bi-)
sulfites. Sulfites are included, as antioxidants.
When sulfite allergy is present, local anesthetics not
containing a vasopressor should be used. ( e.g.,
prilocaine “ Plain” and mepivacaine “ Plain”.

• Latex sensitivity has grown to become a significant

problem among all health professionals and their
patients. The use of vinyl as a latex substitute has
minimized the occurrence of allergic reactions.
224
• Management of the patient with a true,
documented, and reproducible allergy to local
anesthetics varies according to the nature of the
allergy.
• If the allergy is limited to the ester drugs (e.g.
procaine, propoxycaine, benzocaine, or
tetracaine), the amides (e.g., articaine, Lidocaine,
mepivacaine, or prilocaine), may be used
because cross – allergenicity, although possible,
is quite rare.
• If the local anesthetic allergy was actually an
allergy to the Parabens, preservative, an amide
local anesthetic may be injected if it does not
contain any preservative.

225
 Anaphylaxis
• Anaphylaxis is an acute systemic (multi-
system) and severe Type I Hypersensitivity
reaction
• Reactions involving one organ system are
referred to as localized anaphylaxis.

• Examples include bronchial asthma, in

which the respiratory system is the target
and uticaria, in which skin is the target
organ.
226
 PATHOPHYSIOLOGY
• The clinical manifestations of allergy result from
an antigen – antibody reaction. Such reactions are
a part of the body’s defense mechanisms (i.e.,
immune system).

• For acute, immediate allergy or for anaphylaxis to

occur, three conditions must be met
1) An antigen – induced stimulation of the immune
system with specific IgE antibody formation.
2) A latent period after the initial antigenic exposure
for sensitization of mast cells and basophils.
3) Subsequent reexposure to that specific antigen.
227
 SIGNS & SYMPTOMS

• Respiratory - bronchospasm, increased mucous

production, coughing, chest tightness, dyspnea, wheezing
• Cardiovascular- vasodialation, increased vascular permeability,
lightheadedness, syncope, tachycardia,dysrhythmia, orthostatic
hypotension and shock
• Gastrointestinal- abdominal pain, nausea, vomiting,diarrhoea
• Urticaria, rhinitis, conjunctivitis
 MANAGEMENT

Speed at which symptoms of allergy appear & the rate at which they
progress determine the mode of management
Delayed onset allergic skin reactions

Terminate dental procedure

P – Position patient comfortably

A-B-C – assess and perform BLS, as needed

D – initiate definitive care:

Observe Patient Administer oral Administer IM/

Histamine blocker oral histamine
Blocker every 4-6 Hrs.

medical consultation.

230
Rapid onset allergic skin reaction
Terminate dental procedure

P- Position patient Comfortably

A-B-C – assess and perform BLS, as needed

D – initiate definitive care:

(No CVS or respiratory Involvement)

Administer oral or IM histamine blocker.

Allow recovery and

Discharge patient.
231
 (CVS and / or respiratory involvement)

P – reposition Patient.

CVS involvement. No CVS involvement.

(supine position with (comfortable)
legs elevated)

Administer 02 and perform

Venipuncture.

Administer epinephrine.
1:1000 in a dose 0.3 ml(adult) 0.15 ml(child)
(SC, IM, )

Call for medical assistance.

Administer histamine Blocker (IM)

diphenhydramine 50 mg,
permit recovery and discharge patient.
232
 Respiratory allergic reaction
Terminate dental procedure.

P- Position patient Comfortably.

A-B-C – assess and perform BLS, as needed.

D – initiate definitive care:

Remove materials from patient’s mouth.

Call for medical assistance.

Administer bronchodilator,
epinephrine.
(Inhalation, SC, IM, IV)

Monitor vital signs.

Administer histamine blocker (IM)

233
Hospitalize or discharge patient.
 LARYNGEAL OEDEMA
Terminate dental procedure

P – Position patient comfortably

A-B-C – assess and perform BLS, as needed

D – Initiate definitive care:

call for medical emergency.
Administer epinephrineIM/IV

Maintain airway.
(Head tilt-Chin lift; jaw thrust; use oro or nasopharyngeal airway)
administer O2

Administered additional drugs; histamine blocker; corticosteroid IM/IV

Perform cricothyrotomy.

234
 GENERALISED ANAPHYLAXIS
Terminate dental procedure.

P- Position patient Comfortably.

A-B-C – assess and perform BLS, as needed.

D – Initiate definitive care:

Call for medical assistance

Administer epinephrine IM/IV

Administer oxygen

Monitor vital signs.

Administer additional drugs; histamine blocker, corticosteroidsI M/IV

235
CHEST PAIN

236
 CAUSES OF CHEST PAIN
• CARDIAC RELATED
– Angina pectoris
– Myocardial infarction

• NOT CARDIAC RELATED

– Musculoskeletal pain
– Pericarditis
– Esophagitis
– Hiatal hernia
– Pulmonary embolism
– Dissecting aortic aneurysm
– Acute indigestion
CAUSES
CAUSE FREQUENCY

Angina pectoris. Most common.

Hyperventilation. Common.

Acute myocardial Less common.

Infarction.

238
NONCARDIAC CHEST PAIN CARDIAC CHEST PAIN
• Sharp knife like • Dull
• Stabbing sensation • Aching
• Aggravated by movement • Heaviness, oppressive
• Present only with breathing feeling
• Localised (patient able to • Present all the times
point to one spot) • Generalised – occurs over a
wider area
 CARDIAC CHEST PAIN
• LOCATION OF PAIN- occur substernally or just to the left of
midsternal region
• DESCRIPTION- intense, squeezing, pressing, tightness, heaviness
• RADIATION OF PAIN- radiation occurs to the left shoulder &
medial aspect of the left arm
• DURATION- MI 30 min to several hrs, angina- 3-5 mi
• RESPONSE TO MEDICATION- niroglycerine
– Anginal pain will be relieved but not that of MI
 ANGINA PECTORIS
• Angina a Latin word describing a
spasmodic, cramp like, choking feeling
or suffocating pain
• Pectoris is the Latin word for chest.

Definition : a characteristic thoracic pain, usually substernal;

precipitated chiefly by exercise, emotion, or a heavy meal ; relieved
by vasodilator drugs and a few minute’s rest; and a result of a
moderate inadequacy of the coronary circulation.

241
 Precipitating factors in angina pectoris

 Physical activity.
 Hot, humid environment. Precipitated by factors that produce a
 Cold weather relative inability of the coronary arteries to
 Large meals. supply myocardium with adequate volumes
of oxygenated blood
 Emotional stress.
 Caffeine ingestion.
 Fever, anemia or thyrotoxicosis.
 Cigarette smoking.
 High altitudes.
 Smoke from another person’s cigarettes.
 PREVENTION

• Emotional & physical stress – major elements known to

precipitate chest pain
• Elimination of stress is the primary preventive measure
 CONSIDERATIONS
• Stable angina present ASA III risk
• Patients with unstable angina present ASA IV…..should be managed as
though they has an MI within the past 6 months. Not candidates for elective
dental care
• Length of appointment- short, should cease when the patient demonstrates
signs & symptoms of fatigue
• supplemental oxygen
• Pain control during therapy through appropriate use of LA
• Minimise vasoconstrictor administration in patients at risk
• Consider psychosedation
• Monitor vital signs before treatment
• Nitroglycerine premedication 5 min before start of procedure
 MANAGEMENT
Terminate dental procedure.

P- Position patient Comfortably.

A-B-C – assess and perform BLS, as needed.

D – Initiate definitive care:

If no response
(History of angina) Call for emergency medical
Administer nitroglycerin. assistance. (No history of angina)
Call for emergency
Administer Aspirin
medical assistance.
Administer oxygen.
Administer oxygen.
Monitor and record
Vital sings.
Administer nitroglycerin.
(Pain resolves)
Modify future dental care. Monitor vital sings.

245
 ACUTE MYOCARDIAL INFARCTION
• a clinical syndrome caused by a deficient coronary
arterial blood supply to a region of myocardium
that results in cellular death and necrosis.
• characterized by severe and prolonged substernal
pain similar to, but more intense and of longer
duration than, that of angina pectoris.

Complications
shock, heart failure, and cardiac
arrest.

246
 SYMPTOMS SIGNS
Pain.
 Severe to intolerable.  Restlessness
 Prolonged , > 30 min.  Acute distress
 Crushing, choking.  Skin – cool, pale, moist
 Retrosternal pain Radiates:  Heart rate- bradycardia to
Left arm, hand, tachycardia
Epigastriuim, shoulders,
Neck, jaw.
 Nausea and vomiting.
 Weakness.
 Dizziness.
 Palpitations.
 Cold perspiration.
 Sense of impending doom. 247
 DENTAL THERAPY CONSIDERATIONS
• Stress reduction
• Supplemental oxygen
• Sedation
• Pain control
• Vasoconstrictors relatively contraindicated
• Short appointments
• Elective dental care avoided until at least 6 months after MI
• Acute dental problems – at first managed pharmacologically(antibiotics or
analgesics)
• Invasive treatments – should proceed in a hospital
• Medical consultation
• Anticoagulant or antiplatelet therapy
MANAGEMENT
Terminate dental procedure.

P- Position patient Comfortably.

A-B-C – assess and perform BLS, as needed.

.
D – Initiate definitive care:

Administer oxygen.

Summon emergency Medical assistance.

Administer nitroglycerin

Administer aspirin

Manage pain- parenteralopioids

Monitor vital signs- prepare to manage complications

Transfer to hospital 249
 CARDIAC ARREST
• Angina pectoris, myocardial infarction, and heart failure are three
clinical manifestations of ischemic heart disease (IHD).
• Associated with each of these clinical entities is the possible occurrence
of acute complications that include cardiac dysrhythmias and
cardiopulmonary of collapse.
• The latter is also called cardiac arrest or sudden death.

250
 CARDIAC ARREST

All medical emergency situations may ultimately lead to cardiac

arrest. In most instances prompt recognition and initiation of
effective management of the specific situation presents cardiac arrest
from occurring.

251
 CAUSES OF CARDIAC ARREST

CAUSES FREQUENCY
Myocardial infarction. Most Common.
Sudden death ( no other Most common.
symptoms).
Airway obstruction. Common.
Drug overdose reaction. Common.
Anaphylaxis. Less common.
Seizure disorders. Less common.
Acute adrenal Less common.
insufficiency.
252
 Early access
(A cardiac emergency must be recognized and responded to as quickly as
possible)

Early CPR
(Some efforts at opening the airway, ventilation and blood circulation must occur
as soon as possible)

Early defibrillation
(Identification and treatment of VF is the single most important intervention.)

Early ACLS
(Advanced airway control and rhythm – appropriate IV medications must be
administered rapidly).

254
 MANAGEMENT
Assess level of consciousness.

Call for help.

P-position patient.

A-Open airway.

B-Check for breathing.

Ventilate two times.

Check for carotid artery pulse.

Begin external chest compression

Defibrillation 255
 CPR
Perform external chest compression.

Locate pressure point.

(Hand position: Heel of hand on chest.

[adult]).

Apply pressure: Compress sternum.

1 ½ 2inches (adults).

256
 CPR
Compress at a rate of 80-100 compressions per minute.

Single rescuer: Administer 15 compressions, 2 ventilations.

Team rescuer: Administer 5 compressions, 1 ventilations.

257
CONCLUSION

Understanding the etiology and the efficient management of

medical emergencies in the dental set up is a must so that signs and
symptoms are identified and dealt with at the earliest before they
cause any complication
TRY PREVENTING & BE PREPARED

259
REFERENCES
• Stanley F. Malamed - Medical emergencies in the dental office-5th &
6th edition.
• Crispian scully and cawson – medical problems in dentistry.
• Davidson’s principals & practice of medicine – 20th edition.
• Emergency medicine: Beyond the basics-JADA, Vol. 128, July 1997
853.

260