ภาวะฉุกเฉินทางการแพทย์ (Medical Emergencies) ในคลินิกทันตกรรม • การป้องกัน (Prevention) • การจัดการ (Management) • Emergencies in dental practice can occur to any person, any time. • How to manage, it.
Download ReportTranscript ภาวะฉุกเฉินทางการแพทย์ (Medical Emergencies) ในคลินิกทันตกรรม • การป้องกัน (Prevention) • การจัดการ (Management) • Emergencies in dental practice can occur to any person, any time. • How to manage, it.
ภาวะฉุ กเฉิ นทางการ แพทย ์ (Medical • การป้ องกัน Emergencies) ใน (Prevention) คลิน•ิ กการจั ทันดตกรรม การ (Management) • Emergencies in dental practice can occur to any person, any time. • How to manage, it is the most difficult thing at time occurred. • The majority emergency is syncope. Others – – – – – – – allergic reaction angina pectoris postural hypotension seizures asthmatic attack hyperventilation hypoglycemia • • • • • anaphylactic reaction cerebrovascular accident adrenal insufficiency thyroid storm etc Composition of consciousness – – – – Brain O2 Glucose Effective hemodynamic Fact … of human brain • Uses O2 approx. 20% of total O2 • Uses glucose approx. 65% of total glucose • Uses approx. 20% of total circulation/min (750 Balance mechanism of : •Hemodynamic •Respiration •Metabolism •Neurologic Caused from impair …….. – Hemodynamic – Respiration – Metabolism How to avoid these complications? • Prevention is the best • Good history taking • Good preoperative preparation • Good operative controls Possible causes of unconsciousness in the dental office • Vasodepressor syncope • Drug administration /ingestion • Orthostatic hypotension • Epilepsy • Hypoglycemic reaction • Acute adrenal insufficiency • Acute allergic reaction • Acute myocardial infarction • Cerebrovascular accident • Hyperglycemic reaction • Hyperventilation syndrome Alteration of consciousness • • • • • • • Cerebrovascular accident (CVA) Seizures Hypoglycemia / Hyperglycemia Adrenal insufficiency Thyroid storm Hyperventilation Drug overdose Syncope is the most common occurred. Factors influence •Stress and anxiety •Health status •Drugs How syncope occur? In normal : circulation compensation mechanism play role in correction of deficiency O2 supply How syncope occur? In syncope : circulation compensation mechanism fail to increase O2 need Signs for syncope Early : Feeling of warmth Loss of color : pale or ashen=gray skin tone Heavy perspiration Complaints of feeling “bad” of “faint” Nausea Blood pressure approximately baseline Signs for syncope Late : – Pupillary dilation – Yawning – Hyperpnea – Cold hands and feet – Hypotension – Bradycardia – Dizziness – Loss of consciousness Critical consideration • Timing of detection and correction • Maintain O2 level to the brain : Airway, Breathing, Circulation (ABC - Basic life support) Orthostatic hypotension • • • • Failure of the baroreceptor reflex Loss of compensate mechanism Reflex bradycardia Loss of consciousness Drugs producing orthostatic hypotension Category Generic name Proprietary name Antihypertensives Guanethidine Ismelin Phenothiazines Chlorpromazine Thioridazine Doxepin Amitriptyline Imipramine Thorazine Mellaril Sinequan Elavil Tofranil Presamine Demerol Morphine Dopar Larodopa Tricyclic antidepressants Narcotics Meperidine Morphine Antiparkinson drugs Levodopa (L-dopa) Unconsciousness Assessment : Check for Breathing – Look the chest to rise and fall – Listen for air escaping during exhalation – Feel for the flow of air Unconsciousness : no response to stimuli P - position : SUPINE Call for help : EMS activation A, B = Airway (head tilt chin lift) Artificial Assisted Breathing (if no self respiration) C = check circulation Carotid pulse present Check medical Carotid pulse absent Activate history Vital EMS signs Reco unreco very very Initiate Orthos Vasodepre CPR Immedia tatic ssor Sequence of BCLS • Assessment • EMS Activation • ABCs of CPR • D of Defibrillation ABCs of CPR • Airway • Breathing • Circulation Airway • Position the victim • Rescuer position • Open the Airway – Head Tilt - Chin Lift Maneuver – Jaw Thrust Maneuver – Recommendations for Opening the Airway Classification of causes of unconsciousness by mechanism Mechanism Inadequate delivery of blood or oxygen to the brain Clinical example Acute adrenal insufficiency Orthostatic hypotension Vasodepressor syncope Classification of causes of unconsciousness by mechanism Mechanism Systemic or local metabolic deficiencies Clinical example Acute allergic reaction Drug ingestion and adminstration Nitrites and nitrates Diuretics Sedatives-narcotics Local anesthetics Hyperglycemia Hyperventilation Hypoglycemia Classification of causes of unconsciousness by mechanism Mechanism Direct or reflex effects on nervous system Clinical example Cerebrovascular accident Convulsive episodes Psychic mechanisms Emotional disturbances Hyperventilation Vasodepressor syncope Causes of chest pain Non-cardiac related Cardiac related • Angina pectoris • Myocardial infarction • • • • • • Muscle strain Pericarditis Esophagitis Hiatal hernia Pulmonary embolism Dissecting aortic aneurysm • Acute indigestion • Intestinal “gas” Chest pain is one of the major clinical clues to the presence of significant heart disease. Definition of Terms “Atherosclerosis” is a special type of thickening and hardening of medium - sized and large arteries because of deposits of a fatty substance. •is an ongoing process •is a reactive biologic response of arteries to the forces being Atherosclerosis is the major factor underlying all forms cardiovascular disease. Normal structure Development of atherosclerosis Proliferativ e change Development of atherosclerosis Lipid depositi on The development of ACS Early plaque formation Significant plaque formation Plaque rupture Thrombus Coronary artery disease is the presence of atherosclerosis in the coronary arteries. • Angina pectoris • Myocardial infarction Angina is a transient discomfort (usually less than 15 minutes) due to a temporary lack of adequate blood supply to the Myocardial infarction is defined as death of heart muscle (myocardium) as the result of prolonged Acute coronary syndromes encompasses symptomatic condition resulting in an inadequate blood AMI (heart attack) is defined as death of heart tissue due to blockage of a coronary artery caused by Unstable angina • Angina that is continuing, prolonged or occurring at rest. • Represents a syndrome that lies between angina pectoris and AMI. Unstable Angina pectoris ----Angin ---------> AMI a Risk factors : Heart attack •Risk factors that cannot be changed Age Heredity Gender Race • Risk factors that can be changed Cigarette Physical smoking inactivity High blood Diabetes pressure Obesity High blood Excessive cholesterol stress Diagnosis Electrocardiogram (EKG) Exercise stress test Echocardiogram Coronary angiography Treatment 1. Coronary artery bypass graft surgery (CABGS) 2. Medical therapy 3. Percutaneous Transluminal Coronary Angioplasty (PTCA) หรือ Percutaneous Coronary Intervention (PCI) Drugs and bleeding in patient with CAD • Aspirin • Plavix • Ticlid • Coumadin Angina pectoris • Potential problem related to dental care 1. Stress and anxiety related to dental visit may precipitate angina attack 2. Myocardial infarction 3. Sudden death Angina pectoris • Prevention of complication 1. Detection of patient 2. Referral of patient for medical evaluation and treatment • Prevention of complication 3. Known case with medical treatment for angina –Stress reduction protocol •Premedication •Open and honest communication •Morning appointments •Short appointments •Nitrous oxide - oxygen Emergency action plan for a person with signals of heart attack Unknown case of CAD Recognize the signals of a heart attack Stop activity and sit or lie down Known case of CAD Recognize the signals of heart attack Stop activity and sit or lie down Take 1 nitroglycerin tablet at a time at 3 to 5 minutes intervals Wait about 5 Transport to minutes to see if patient to maximum total dose of 3 tablets. If the symptom hospital go • Potential problem related to dental care 1. Cardiac arrest 2. Myocardial infarction 3. Angina pectoris 4. Congestive heart failure 5. Bleeding tendency secondary to anticoagulant • Prevention of complication 1. No routine dental care until at least 6 months after infarction 2. Medical consultation –Current status –Medication used 3. Stress reduction protocol –Premedication –Open and honest communication –Morning appointment –Short appointment –Nitrous oxide - oxygen 4. Avoid excessive amounts of epinephrine Management of Acute Myocardial Infarction Step 1. Diagnosis Administer nitroglycerin 2. Initiate BLS 3. Summon medical assistance 4. Administer oxygen and monitor vital signs 5. Relive pain Morphine Nitrous oxide - oxygen 6. Transport patient to ผูป้ ่ วยชายอายุ 68 ปี มาด ้วยมีสว่ น แหลมคมของฟันกรามบนซ ้าย เป็ นฟัน ทีร่ ับการร ักษาคลองรากฟันและมีตวั ฟัน แตกออก วางแผนการร ักษาโดยการ ถอนฟัน จากการซักประวัติ ผูป้ ่ วยเป็ น โรคหลอดเลือดหัวใจ ได ้ร ับการร ักษา โดยการทาบอลลูน และร ับประทานยา อยูเ่ ป็ นประจา Medical Problem List 1. Coronary 4. Old CVA : Left artery disease : hemiparesis 5 double - vessel yrs ago at present : Status : post PCI complete พ.ค. + มี.ค. 46 recovery at present : 5. Mild renal asymptomatic insufficiency 2. DM : controlled 6. Mild late onset 3. HT : controlled Current medication 1. Aspent gr. V 1 x 1 orally pc. 2. Plavix 1 x 1 orally pc. 3. Plendil 1 x 2 orally pc. 4. Minidiab 1 x 1 orally pc.