Transcript Emergency in Dentistry: Part I

Emergency in Dentistry:
Part II
Hypersensitivity
Chest discomfort
Respiratory difficulty
Altered consciousness
Metabolic problems
Hypersensitivity Reactions
Type I:
- immediate, acute and lifethreatening
- mediated primarily by IgE
- previous exposure history
Hypersensitivity Reactions
Skin signs:
- erythema, urticaria, pruritis, angioedema
Respiratory tract signs:
- wheezing, mild dyspnea
- stridor, moderate to severe dyspnea
Hypersensitivity Reactions
Manifestation
Delayed onset skin signs:
Erythema, urticaria, pruritis,
angioedema
Management
1.
2.
3.
1.
2.
Immediate onset skin signs: Erythema,
urticaria, pruritis, angioedema
3.
4.
5.
Stop all drugs that currently use
IM or IV Allermin/CTM or
Benadryl p.o.
Prescribe antihistamine
Stop all drugs that currently use
SC, IM or IV Epinephrine (1:1000)
0.3ml, q5m if S & S progress
IM or IV Allermin/CTM or
Benadryl p.o.
Monitor vital signs
OBS for 1 hr and prescribe
antihistamine
Manifestation
Management
1.
2.
Respiratory signs (wheezing, mild
dyspnea) with or without skin signs
Stridorous breathing (crowing sound),
moderate~severe dyspnea
Epinephrine
3.
4.
Stop all drugs that currently use
In sitting position and give O2
Prescribe epinephrine and
antihistamine
Steam inhalation with
bronchodilator (Atroven +
Berotec or Ventolin)
Same as above and prepare to ER
Nasal cannula
Manifestation
Management
1.
2.
Anaphylaxis (with or without skin
3.
signs): malaise, wheezing,
moderate~severe dyspnea, stridor,
cyanosis, total airway obstruction,
nausea & vomiting, abdominal cramps, 4.
urinary incontinence, tachycardia,
5.
hypotension, cardiac dysrhythmia,
cardiac arrest
6.
Stop all drugs that currently use
Put the p’t in supine position on
back board and give O2
Administer
epinephrine/antihistamine as
above
Monitor vital signs and prepare
for BLS
Steam inhalation with
bronchodilator (Atroven +
Berotec or Ventolin)
Consider if cricothyrotomy if
laryngospasm cannot relieved
Differential Diagnosis of Acute
Chest Pain: Common Causes
Cardiovascular: angina pectoris, MI
Gastrointestinal: dyspepsia (heart burn),
hiatal hernia, reflux esophigitis, gastric ulcer
Musculoskeletal: intercostal muscle spasm
Psychologic: hyperventilation
Differential Diagnosis of Acute
Chest Pain: Uncommon Causes
Cardiovascular: pericarditis, dissecting
aneurysm
Respiratory: pulmonary embolism, pleuritis,
tracheobronchitis, mediastinitis,
pneumothorax
Gastrointestinal: esophageal rupture,
achalasia
Musculoskeletal: chostochondritis
Psychologic: psychogenic chest pain
Chest Discomfort:
--- AMI or angina pectoris
Pain pattern
- Characteristics: squeezing, bursting, pressing,
burning or choking
- Location: substernum
- Refer pain: L’t shoulder, arm, neck
or mandible
- Associated with exertion, anxiety
- Relieved by vasodilator (ex. NTG) or
rest
- May accompanied by dyspnea, nausea& vomiting sensation,
palpitation
1.
2.
3.
4.
5.
Terminate all procedures
Semi-reclined position
Sublingual NTG
O2
Check vital signs
Discomfort relieved
6. Assume angina pectoris was present
7. Slowly taper O2 over 5min
8. Modify dental treatment
Angina pectoris
Still discomfort after 3min
Give 2nd NTG
Still discomfort after 3min
Give 3rd NTG
Still discomfort after 3min
NTG
0.6mg/tab
10. Assume myocardial infarction in progress
11. On IV line
12. Prepare transport to ER
If highly suspected AMI
MONA: Morphine, Oxygen, NTG, Aspirin
Respiratory Difficulty:
Asthma
Hyperventilation
Chronic obstructive pulmonary disease
(COPD)
Foreign body aspiration
Gastric contents aspiration
Manifestations of An Acute
Asthmatic Episode:
Mild to moderate
- wheezing
- dyspnea
- tachycardia
- coughing
- anxiety
Manifestations of An Acute
Asthmatic Episode:
Severe
- intense dyspnea with flaring of nostrils &
use of accessory muscle
- cyanosis of mucous membrane & nailbeds
- minimal breathing sound on auscultation
- flushing
- extreme anxiety
- mental confusion
- perspiration
Asthma
1.
2.
3.
4.
5.
Terminate all procedures
Fully sitting position
Bronchodilators (Atrovent/Berotec)
O2
Check vital signs
S & S relieved
6. Monitor of recovery state
7. Consult physician
Signs & symptoms continue
6. Give Epi 0.3ml of 1: 1,000 IM
or SQ
7. Build up IV line
8. Monitor vital signs
S & S not relieved
9. Prepare to ER
10. Add steroid therapy
Manifestations of
Hyperventilation Syndrome:
Neurologic
- dizziness
- tingling or numbness of fingers, toes
or lips
- syncope
Respiratory
- increased rate & depth of breaths
- SOB
- chest pain
- xerostomia
Manifestations of
Hyperventilation Syndrome:
Cardiac
- palpitations
- tachycardia
Musculoskeletal
- myalgia
- muscle spasm
- tremor
- tetany
Psychologic
- extreme anxiety
Management of Hyperventilation
Syndrome:
Terminate all procedures
On fully upright position
Verbally calm patient
Breath CO2-enriched air
Add Valium 10mg IM or IV; Dormicum 5mg
IM or IV
Monitor vital signs
Anxiety
Increased cathecholamine
release
Decreased peripheral
vascular resistance
Pooling of blood
periphery
Decreased ABP
Reflex vagally mediated
bradycardia, nausea, weakness &
hypotension
Compensatory mechanisms cause
increased HR, feeling of warmth, pallor,
perspiration, rapid breathing
Decompensation occur
Reduced cerebral
blood flow
Vasovagal syncope
Lightheadness, syncope
(if prolong)
Seizure activity
Vasovagal syncope
Prodrome:
• Terminate all procedures
• Supine position with leg elevation
• Attempt to calm patient
• Cool towel to forehead
• Monitor vital signs
Syncopal episode:
1. Terminate all procedures
2. Supine position with leg elevation
3. Check breathing
If absent:
4. Start BLS
5. Prepare to ER
6. Consider other cause
Atropine 1mg/amp
Used in severe
bradycardia
Not exceed 2mg
If present:
4. Ammonia under nose
5. Monitor vital signs
6. Plan anxiety control at next visit
Manifestations of Seizure Attack:
Isolated, brief seizure
- tonic-clonic movement of trunk &
extremities
- loss of consciousness
- vomiting
- airway obstruction
- loss of urinary & anal sphincter control
Repeated or sustained seizure (status
epileptics)
After seizure attack
Patient unconscious
2.
3.
4.
5.
Place on side and
suction airway
Monitor vital signs
Initiate BLS
Administer O2
Prepare to ER
1.
2.
3.
If sustained
1.
Patient conscious
1.
2.
3.
4.
Diazepam 5mg/min IV
Dormicum 3mg/min IV
or IM
Dialantin 10~15mg/kg IV
Suction airway
Monitor vital signs
Administer O2
OBS for at least 1hr
and consult
physician
Manifestation of acute hypoglycemia
Mild
Hunger
Nausea
Mood change
Weakness
Moderate
Severe
Tachycardia
Perspiration
Hypotension
Pallor
Unconsciousness
Anxiety
seizures
Behavior change
Hypoglycemia
Terminate all procedures
Mild S & S:
• Administer oral
glucose source
• Monitor vital signs
• Consult physician
• Intake before next
visit
Moderate S & S:
1. Administer oral
glucose source
2. Monitor vital signs
3. IV D50, 50ml or
glucagon 1mg
4. Consult physician
Severe S & S:
1. IV D50, 50ml or
glucagon 1mg
2. Prepare to ER
3. Monitor vital signs
4. Give O2
Manifestations of acute adrenal
insufficiency:
Weakness
Feeling of extreme fatigue
Confusion
Hypotension
Nausea
Abdominal pain
Myalgias
Partial or total loss of consciousness
Management of acute adrenal
insufficiency:
Terminate all procedures
Supine position with leg elevation
Administer hydrocortisone 100~200mg or
Decardron 5~10mg
Administer O2
Monitor vital signs
Set up IV line
Start BLS if indicated
Decardron 5mg
Hydrocortisone 100mg
Thanks for Your
Attention !!!
Manifestation and management of local anesthesia toxicity
Manifestations
Management
Mild: talkativeness, anxiety, slurred
speech, confusion
Stop administer L.A.
Monitor vital signs
OBS in office for 1 hr
Moderate: stuttering speech,
nystagmus, tremors, headache,
dizziness, blurred vision, drowsiness
Stop administer L.A.
Monitor vital signs
Place in supine position
Administer O2
OBS in office for 1 hr
Place in supine position
Severe: seizure, cardiac dysrhythmia or If seizure attackseizure algorism
arrest
Institute BLS if necessary
Prepare to ER
Suggested maximum dosage of local anesthetics
Local anesthetics
Maximum No.
2% Lidocaine with Epinephrine
10
Mepivacaine
6