Medical Emergency in Dental Practice

1. General Dental Practice Commission
Asia Pacific Dental Federation
•Dr. Sudin Shakya, Chairman
• Prepared by:
•Dr. Saroj Singh , Chief Coordinator
•Dr. Bodh Bikram Karki, Member
•Dr. Archana Yadav, Member
•Dr. Pramina Shakya, Member
•Dr. Priyanka Joshi, Member

2. Basic Management Of Medical
Emergency In Dental Practice
And
Emergency Kit
Be Prepared Be Alert Anticipate

3. Reality of Dental Emergencies
Almost Always Almost Never

4. Medical Emergencies Anywhere…
The skills you acquire for the management of a
medical emergency can be applied anywhere.
Disasters of any kind may occur in your
community and require your skill and expertise.

5. Incidence
 10% of all non-accidental deaths that occur
each year in the dental office are of a
sudden, unexpected nature, occurring in
supposedly healthy patients*
 Older patient populations are generally at
risk because of lifelong gradual deterioration
of the critical systems
*Emery RW et al; Dental Clinics of NorthAmerica 1999

6. 1. Detection
2.
Reporting
3. Response
4. On Scene
Care
5. Care in
Transit
6. Definitive
Care

7. P-R-A-Y
 Preparedness:- of the office and personnel to treat the
impending emergency in a timely and efficient manner.
 Recognition:- of predisposing signs and symptoms of an
impending emergency
 Action:- Develop a plan to stabilize and support the
emergency patient
 Yell:- To know when and where to obtain help in
activating EMS when necessary

8. What Are the Most Common Medical Emergencies?
Emergency Number Reported
Syncope 15,407
Mild allergic reaction 2,583
Angina pectoris 2,552
Postural hypotension 2,475
Seizures 1,595
Asthmatic attack 1,392
Hyperventilation 1,326
“Epinephrine reaction” 913
Hypoglycemia 890
Cardiac arrest 331
Anaphylactic reaction 304
Myocardial infarction 289
Local anesthetic overdose 204
Acute pulmonary edema (heart failure) 141
Diabetic coma 109
CVA 68
Adrenal insufficiency 25
Thyroid storm 4
TOTAL 30,608
Malamed SF; Medical Emergencies in the Dental Office. 6th Edition.2007

9. When Do Medical Emergencies Occur?
Treatment %
Tooth extraction 38.9
Pulp extirpation 26.9
Unknown 12.3
Other treatment 9.0
Preparation 7.3
Filling 2.3
Incision 1.7
Apicoectomy 0.7
Removal of fillings 0.7
Alveoloplasty 0.3
Matsuura H; Anesth Prog 1990
Timing %
During or after LA 54.9
During Treatment 22.0
After Treatment 15.2
After leaving office 5.5
Immediately before
Treatment
(waiting room)
1.5

10. The Number of Medical Emergencies During Dental Treatment
is Predicted to Increase
 Increase number of older patients
 Medical advances
 Drug therapy
 Surgical techniques
 Life-prolonging treatments
 Increased complexity and length of
dental appointments as dental
technology advances

11. PREVENTION
“When you prepare for an emergency, the emergency
ceases to exist”
Goldberger E. Treatment of cardiac emergencies, ed 5, St. Louis, Mosby, 1990
“To be forewarned is to be forearmed”
Malamed SF. Medical emergencies in the dental office, ed 6, St. Louis, Mosby, 2007
“An ounce of prevention is worth a pound of cure”
Benjamin Franklin

12. Prevention
 Medical history
 Medications
 Allergies
 Hospitalizations
 Physical exam
 General survey
 Vital signs
 Head/Neck/Oral
 Medical risk assessment (ASA risk classification)
 Geriatric considerations
 Patient’s level of apprehension, stress, anxiety
 Medical consultation
 Putting all of the information together to make management decisions

13. Medical History: Never Treat a Stranger
 Must be written and oral
 Updated and documented
 Determine acute vs. chronic symptoms
 Determine physiologic reserve
 Medications
 Indications, contraindications, drug interactions, side effects
 Is there a need to regulate dose peri-operatively
 Allergies
 What is the reported response?
 Is this a known side-effect or a true allergic reaction?

14. General Survey (Visual Inspection)
 General state of health
 Nutritional status
 Skin
 Jugular vein distention
 State of awareness or level of consciousness
 Odors of the breath
 Gait
 Posture
 Body movements (motor activity)
 Speech
 Signs of distress

15. Which conditions might be detected on a general survey?
 Congestive heart failure
 Prior Stroke
 Parkinson’s Disease
 Diabetes
 Anxiety
 Obesity related disorders
 Liver disease/ alcoholism
 Hyper or hypothyroidism
How could you detect these problems on a general survey?

16. Signs of Distress
 Cardiac or respiratory (clutching chest, pallor, diaphoresis, labored
breathing, wheezing, cough)
 Anxiety or depression (anxious face, fidgety movements, cold moist palms,
inexpressive or flat affect, poor eye contact, psychomotor slowing)
 Pain
 Wincing, diaphoresis, protectiveness of painful area
 Pain is associated with more than 60% of all emergencies*
 Early appointments
 Anxiety
 Medically compromised
*Emery RW et al; Dental Clinics of North America 1999

17. Interpretation of Blood Pressure
Classification BP (mm Hg) Tx Considerations
Optimal <120/<80 Proceed with Tx
Normal <130/<85 Proceed with Tx
High normal 130-139/85-89 Proceed with Tx
Hypertension
Stage I (mild) 140-159/90-99 Proceed with Tx
Medical referral
Stage II (moderate) 160-179/100-109 Selective Tx (atraumatic extraction, Biopsy)
Medical referral
Stage III (severe) 180-209/110-119 Delay elective Tx
Emergent nonstressful Tx (I&D) Medical referral
Stage IV (very severe) >210/>120 Delay Tx Medical referral

18. Hypertension
Isolated systolic hypertension is
associated with a 2-fold increase in
cardiovascular death and a 2.5-fold
risk of stroke compared with those
who are normotensive
Shekelle RB, et al. Hypertension and the risk of stroke in an elderly population. Stroke 1974; 5: 71-75

19. Description
ASA
I Healthy
II Mild systemic disease
(does not interfere with daily living; medically stable and/or controlled) Examples: DM (controlled), epilepsy,
pregnancy, stage I or II HTN, history of cancer in remission, mild COPD, extreme dental fear
Risk factors: smoker, alcohol abuse, mild obesity, >60 years of age
III. Severe systemic disease that limits activity but not incapacitating (alters daily living) Examples:
stable angina, >6 months status post(s/p) MI, >6 months s/p CVA, DM with systemic sequelae,
stage III HTN, morbid obesity, COPD, exercise-induced asthma
IV. Severe systemic disease that is a constant threat to life and incapacitating
Examples: unstable angina, <6 months s/p MI, poorly controlled DM, stage IV HTN, <6 months s/p
CVA
V. Moribund; not expected to survive 24 hours
Examples: end-stage disease (renal, hepatic, cancer, cardiovascular, respiratory)
-E Suffix added to ASA classification to denote an emergency procedure
ASA Risk Classification

20. Prevention
 Train staff and yourself
• Office protocol
• Management goals
• EMS and M.D. telephone numbers
• Team certified in CPR, ACLS
• Mock simulations
Have essential
• Equipment
• Medications

21. Preparation for a Medical Emergency
 Basic life support
 Team management
• Team member 1: BLS, stay with patient
• Team member 2: Bring emergency kit
• Team member 3: Assist with BLS, monitor VS,
activate EMS system, prepare drugs
 Equipment
 Medications

22. Emergency Equipment and Medications
 Accessible
 Functional
 Medical emergency kits
• Individually prepared
• Commercial

23. 2010 Handbook of Emergency Cardiovascular Care
for Healthcare Providers CPR Review

24. Required Emergency Equipment
Eyes (doctor, assistant)
 Portable “E” tank oxygen
 Oxygen delivery systems
• Nasal cannula
• Face mask
• Nonrebreathing mask with oxygen reservoir
• Bag-valve-mask device
 Stethoscope
 Sphygmomanometer
 Yankauer (Tonsil) suction
 Battery powered light source
 Airways (oral and nasal)
 Automated external defibrillator (AED)

25. Oxygen Supplementation/Delivery Systems
Nasal cannula Face mask Nonrebreather
Bag-valve-mask
Mouth-to-mask
Mouth-to-Mouth

26. AED (Automated external defibrillator)

27. Timing for BLS and Defibrillation is Critical!
Eisenberg MS, et al; JAMA 1979
Cardiac Arrest Resulting from VF
Initiation of CPR
(minutes)
Arrival of ACLS
(minutes)
Survival Rate (%)
0-4 0-8 43
0-4 16+ 10
8-12 8-16 6
8-12 16+ 0
12+ 12+ 0
Student/dental
surgeon
Ambulance

28. Supplemental Emergency Equipment
 Laryngoscope
 Endotracheal tubes
 Forceps
 EKG/Defibrillator
 Pulse oximeter
 Nebulizer mask
 Normal saline
 Syringes
 18-and 20-gauge angiocatheters
 Sterile water for injection

29. Classification of Medical Emergencies:
Signs and Symptoms
 Unconsciousness
 Vasodepressor syncope
 Orthostatic hypotension
 Acute adrenal insufficiency
 Respiratory distress
 Airway obstruction
 Hyperventilation
 Asthma (bronchospasm)
 Altered consciousness
 Diabetes mellitus: hyperglycemia and hypoglycemia
 Thyroid gland dysfunction: hyper- and hypothyroidism
 Cerebrovascular accident
 Seizures
 Drug-related emergencies
 Drug overdose reactions
 Allergy
 Chest pain
 Angina pectoris
 Acute myocardial infarction
 Sudden cardiac arrest

30. Classification of Medical Emergencies:
Risk Factors (Stress, Cardiovascular)
Noncardiovascular Cardiovascular
Stress-related Vasodepressor syncope
Hyperventilation Seizure
Acute adrenal insufficiency
Thyroid storm
Asthma (bronchospasm)
Angina pectoris
Acute myocardial infarction
Acute heart failure (pulmonary
edema)
Cerebral ischemia and infarction
Sudden cardiac arrest
Severe hypertension
Non-stress-related Orthostatic (postural)
hypotension Overdose (toxic)
reaction Hypoglycemia
Hyperglycemia
Allergy
Acute myocardial infarction
Sudden cardiac arrest

31. Required Emergency Drugs
 Oxygen
 Nitroglycerin 0.4 mg tablets or
0.4 mg spray
 Aromatic ammonia inhalant
 Oral sugar (glucola, fruit juice)
 Aspirin 160-325 mg
 Albuterol (proventil) metered
dose inhaler
 Epinephrine 1 mg/ml (1:1000 dilution)
ampule/epinephrine pen
 Chlorpheniramine (Chlor-Trimeton) or
Diphenhydramine (Benadryl) 10 mg/ml
 Hydrocortisone 300 mg ampule or
Solumedrol 10mg/ml
 Diazepam or midazolam 5 mg/ml
 Glucagon 1 mg/dose
 D50W 50 ml (50% dextrose in water)
 Phenylephrine
Non-Injectable Injectable

32. Onset of Action (Fastest to Slowest)
 Endotracheal tube (epinephrine,
lidocaine, atropine, naloxone,
flumazenil)
 Intravenous
 Intranasal (midazolam)
 Sublingual or intralingual
 Intramuscular
 Vasus lateralis
 Mid-deltoid
 Gluteal region

33. Where to Inject?
The ideal route for emergency drugs is IV
,
if the provider is trained to do so.

34. Supplemental (ACLS Advance Cardiovascular Life Support)
Emergency Drugs
 Epinephrine 1 mg (10 ml of 1:10,000) – VF, pulseless VT, asystole, PEA
 Vasopressin 40 U – Ventricular Fibrillation, pulseless Ventricular T, asystole, PEA
 Atropine – 1 mg (asystole, PEA); 0.5 mg (bradycardia)
 Amiodarone – 300 mg (VF, pulseless VT), 150 mg (VT with pulse)
 Lidocaine 1mg/kg – VF, pulseless Ventricular Tachycardia
 Adenosine 6 mg/12 mg – Supraventricular Tachycardia (SVT)
 Morphine 2-4 mg – chest pain with Acute Coronary Syndrome unresponsive to nitroglycerin
 Naloxone (Narcan) 0.4 mg/ml – Respiratory and neurologic depression due
to opiate
 Flumazenil (Romazicon) 0.1 mg/ml – Reverse respiratory depression due to
benzodiazepine
 Succinylcholine 20 mg/cc – Intubation
 Furosemide 0.5-1 mg/kg – Pulmonary edema

36. Oxygen Supplementation
Rosenberg M; JADA2010

37. Management Goals
 Discontinue dental treatment
 Call for help
 Positioning
 Evaluate and maintain (CPR)
• Airway
• Breathing
• Circulation
• Defibrillation
 Diagnosis
• Vital signs (and continued monitoring)
• Medical history
• Signs and symptoms
• Dental treatment rendered and drugs administered
 Treatment
• Minor emergencies (office)
• Life-threatening emergencies (initiate treatment while awaiting transport to acute care
facility)

38. Positioning
 Patients who lose consciousness should
be placed in the supine (horizontal)
position.
• Syncopal patients should
be in the Trendelenburg
position
 Patients in respiratory distress associated
with asthma, heart failure, or
hyperventilation should be positioned
upright or semi-upright.
 Do not attempt to move the patient from the dental chair.

39. A 55 year old male complains of chest
pain during the extraction of an
erupted wisdom tooth under local
anesthesia
 Differential diagnosis?
 Treatment?
 Treatment consideration for patients
with cardiac disease?
Case #1

40. Life-Threatening Causes of Chest Pain
 Acute coronary syndrome
• Unstable angina
• MI
 Aortic dissection
 Pulmonary embolism
 Tension pneumothorax
 Esophageal rupture

41. Is it Angina or an MI????
 Angina
 > O2 demand than supply
 Temporary myocardial
ischemia
 No myocardial damage
 Pain usually of short
duration
 Variants
 Stable Unstable
 Pain at rest
 Myocardial Infarction
 O2 demand vs supply
issue over longer
time period
 Results in myocardial
damage to the
muscle supplied by
the occluded vessel
 Pain, diaphoresis,
nausea, vomiting,
shortness of breath

42. Presentation Noncardiac Cardiac
Type of pain Sharp, knifelike, stabbing 80% of cases: dull, aching, crushing, heaviness
Location of pain Localized (able to point to one spot) Generalized (retrosternal, substernal, left arm,
mandible, neck)
Other symptoms:
Nausea/Vomiting/Sweatin
g/SOB/Dizziness
Yes Yes
Duration of symptoms PE: minutes to <1 hour
Prolonged
Angina: 2-10 minutes
MI: >15-20 minutes
Risk factors PE: pelvic or leg Fx, neoplasm,
immobility, obesity
CAD (tobacco, HTN, hypercholesterolemia,
diabetes)
Associated events GERD: Postprandial
Musculoskeletal: Movement
Angina/MI: physical exertion, emotional stress
MI: coronary artery occlusion, spasm, or
thrombosis at rest
Pain relief GI: Antacids or belching
Peptic ulcer: Food
Angina: rest or nitroglycerin
MI: morphine
Differential Diagnosis of Chest Pain
Malamed SF. Emergency medicine: beyond the basics. JADA 1997; 128: 483 O’Connor RE, et al; Circulation 2010

43. Negative cardiac History
Noncardiac symptoms
Positive cardiac History
“Yes” to any cardiac symptom
1. Hyperventilation
2. GI (GERD, peptic ulcer, esophageal spasm, pancreatitis,
esophageal rupture, biliary disease)
3. Musculoskeletal (costochondritis, rib fracture, cervical disc)
4. Pulmonary (PE, pulmonary HTN, pneumonia, pleuritis)
5. Psychogenic (panic disorder)
6. Other (herpes zoster)
BLS
Oxygen Vital signs
Continued
…
Refer to M.D.
Chest Pain
Position patient erect or semierect

44. …Continued
Systolic BP?
<90 mm Hg or ≥30 mm Hg below baseline
Suspect MI
>90 mm Hg Suspect angina
Call EMS NS IV bolus
Aspirin 160-325 mg
Cardiac arrest?
VS & EKG
ACLS/AED
Aspirin 160-325 mg
Nitroglycerin 0.4 mg SL
Pain relieved
Pain persists
Defer dental Tx
Refer to hospital/M.D.
Call EMS
Repeat nitroglycerin (3 doses total)
If pain persists assume MI
Cardiac arrest?
VS & EKG
ACLS/AED

45. Chest Pain
 30% of acute MI’s are clinically “silent”
 In diabetic patients and the elderly, ischemic chest pain may manifest
as fatigue, epigastric discomfort, or dyspnea
 Dyspnea is the most common anginal equivalent symptom in women
and elderly patients

46. Considerations for Cardiac Disease
 Adequate oxygenation
 Avoid excessive tachycardia, hypertension, hypotension
 Limit local anesthesia to 0.04 mg epinephrine (4 ml of 1:100,000
or 2.2 cartridges)
 Elective surgery postponed 3 - 6 months after MI
 Elective surgery postponed 3 months after Coronary Artery Bypass
Grafting (CABG)
 The elderly, diabetic patients, and women are more likely to present
in an unusual, atypical manner, without classic symptoms or with only
vague, nonspecific complaints

47. CPR: Dental Chair vs. Floor
 Enough room on the floor?
 Chairs used in the Dental office fully
recline
 Consider using a backboard in the chair
 CPR techniques (i.e., ventilation and chest compression)
are effective in both positions and easier to perform in
the dental chair (Lepere AJ, et al. Aust Dent J 2003)

48. What is The Most Common Cause of Cardiac Arrest?
 Ventricular fibrillation
 Anaphylactic shock
 Stroke
 Hypertension

49. Survival Rate for Out-of-Hospital Cardiac Arrest
1Cummins RO;Ann Emerg Med 1989
2Larsen MP, et al; Ann Emerg Med 1993
3Link MS; et al; Circulation 2010
 The most frequent type of cardiac
arrest is ventricular fibrillation (VF)1
 For every minute that passes between
collapse and defibrillation, survival
rates from witnessed VF decrease 7%-
10% if no CPR is provided2
 For every minute that passes,
survival rates from VF decrease 3%-
4% when CPR is provided3

50. Survival Rate for Out-of-Hospital Cardiac Arrest
 5.2% for a one-tier system (i.e., single
provider using either BLS, BLS and
defibrillation or ACLS)
 10.5% for a two-tier system (i.e., 2
responders providing either BLS, BLS
and defibrillation or ACLS)
Nichol G, et al;Ann Emerg Med 1996

51. A 35 year old male who, following 1 hour of lying in
the supine position in the dental chair, stands up
and walks to the reception desk to arrange another
appointment
On reaching the front desk he stands still, feels
and loses consciousness while shivering
 Differential diagnosis?
 Treatment?
Case #2

52. Loss of Consciousness
Absent
Cardiopulmonary arrest (unconsciousness)
Present
Syncope
Call EMS
CPR/ACLS/AED
Supine position
BLS
Oxygen
Vital signs
Breathing & Pulse?
Determine etiology
(Differential Dx)
Call EMS?

53. Differential Diagnosis of Loss of Consciousness
Medical Emergency Circumstances
Hypoglycemia Children, teens to mid-30s, stress, history of diabetes mellitus
Epilepsy Children, teens to mid-30s, stress, tongue biting, urinary or
fecal incontinence
Vasovagal syncope Teens to mid-30s, anxiety, hypotension, bradycardia
Postural hypotension Supine to upright
Local anesthesia (lidocaine) toxicity Intravascular or overdose
Acute adrenal insufficiency Stress
Cerebrovascular accident (CVA) Stress, >40 years
Cardiovascular >40 years, stress
Anaphylactic shock May begin with allergic reaction (skin) and progress to
anaphylaxis (respiratory distress)
Congenital heart lesions Children

54. Clinical Manifestations of Hypoglycemia
 Blood sugar <50 mg/dL
 Classification of diabetes mellitus
• IDDM (Type I): inability of pancreas to
secrete insulin
• NIDDM (Type II): Peripheral resistance to
the action of insulin
 Signs and symptoms
• Mild: hunger, nausea, mood change, weakness
• Moderate: anxiety, confusion, uncooperativeness,
pallor, diaphoresis, tachycardia
• Severe: hypotension, seizures, unconsciousness

55. Signs
 Blood pressure15-
20 % below
baseline
 SBP <90 mm Hg
 Agitation
 Somnolence
 Pallor
 Clammy skin
 Diaphoresis
 Syncope with convulsions at onset
Symptoms
 Weakness
 Fatigue
 Dyspnea
 Nausea
Hypotension

56. Differential Diagnosis of Hypotension
 Vasovagal syncope
 Postural/Orthostatic
 Anaphylactic shock
 Hypovolemia (dehydration, hemorrhage, infection)
 Cardiogenic shock
 Drugs (betablockers, calcium channel blockers)
 Anesthesia related
 Anesthesia overdose
 Light anesthesia
 Hypercarbia/Hypoxemia

57. Treatment of Hypoglycemia
 Supine/Elevate feet
 BLS (Airway, Breathing, Circulation)
 100% oxygen
 Monitor vital signs
 Conscious patient
• Oral sugar (juice, candy, sugar)
• Oral glucose gel/paste
 Unconscious patient
• 50 ml of 50% dextrose (25 g) IV
• Glucagon 1 mg IM

58. Vasovagal Syncope
 “Common faint”
 Pathophysiology: anxiety causing peripheral pooling of blood
resulting in transient cerebral ischemia
 Predisposing factors
• Psychogenic: fright, anxiety, emotional stress, pain, sight of blood
• Nonpsychogenic: erect sitting or standing posture, hunger,
exhaustion, poor physical condition, hot/humid environment
• Ages: 16-35

59. Early
 Feeling of warmth
 Loss of color; pale or ashen-gray skin tone
 Heavy perspiration
 Complaints of “feeling bad” or “felling faint”
 Nausea
 Blood pressure at baseline level or slightly
lower
 Tachycardia
Late
 Pupillary dilation
 Yawning
 Hyperpnea
 Cold hands and feet
 Hypotension
 Bradycardia
 Visual disturbances
 Dizziness
 Loss of consciousness
 Convulsive movements
Presyncopal Signs and Symptoms

60. Pathophysiology of Postural (Orthostatic) Hypotension
 Inadequate peripheral vasoconstrictor activity when assuming an upright position
• A disorder of the autonomic nervous system: a failure of the baroreceptor
mediated increase in peripheral vascular resistance in response to positional
changes
 Risk factors
• Drugs (antihypertensives, sedatives)
• Prolonged recumbency
• Pregnancy
• Advanced age
• Venous defects in the legs (varicose veins)
 Vital signs
• Decreased BP

61. Treatment of vasovagal Syncope & Postural
(Orthostatic) Hypotension
 Supine/Elevate feet
 BLS (Airway, Breathing, Circulation)
 100% oxygen
 Monitor vital signs
 Consider
• Loosen binding clothes (ties, collars, belts)
• Ammonia inhalant (vasovagal syncope)
• Atropine 0.5-1.0 mg IM or IV (HR <50)
• Phenylephrine 5 mg IM (HR >60; hyptotension)
• Call EMS?

62. Local Anesthesia Toxicity
 Classification
• Overdose
• Intravascular injection
 Principles for drug administration
• No drug ever exerts a single action
• No clinically useful drug is entirely devoid of
toxicity
• The potential toxicity of a drug rests in the hands of
the user

63. Signs and Symptoms of Lidocaine Toxicity
Minimal to Moderate Toxicity
 Signs: talkativeness, slurred speech, muscular twitching and tremor in the
face and distal extremities, euphoria, nystagmus, disorientation, vomiting,
elevated BP
, elevated HR, elevated respiratory rate
 Symptoms: light-headedness, dizziness, restlessness, nervousness,
numbness, metallic taste, visual disturbances (inability to focus), auditory
disturbances (tinnitus), loss of consciousness
Moderate to High Toxicity
 Tonic-clonic seizures
 Loss of consciousness (reduced peripheral vascular resistance)
 Depressed BP
, HR, and respiratory

64. CNS
and Cardiovascular
Effects

65. Signs and Symptoms of Epinephrine Toxicity
 Signs
• Elevation in BP (primarily systolic)
• Elevated HR
• Possible cardiac dysrhythmias
 Symptoms
• Fear, anxiety, restlessness, dizziness, weakness
• Throbbing headache
• Perspiration, pallor
• Respiratory difficulty
• Palpitations

66. Maximum Doses of Local Anesthesia
 2% Lidocaine
• With vasoconstrictor: 6.6 mg/kg (manufacturer), 4.4 mg/kg (Malamed)
• Without vasoconstrictor: 4.4 mg/kg (manufacturer and Malamed)
 Epinephrine 1:100,000
• Healthy: 0.2 mg per appointment
• Cardiovascular disease: 0.04 mg per appointment
What about?
• Children
4.4 mg/kg (2 mg/lb) / 1 cartridge/20 lbs
• Elderly
• Organ Compromise

68. Calculating Concentration of Local Anaesthetic
LA concentration is usually expressed as a percentage (%), whilst
maximum safe dose is expressed as mg/kg. Therefore, you need to
convert % to mg/kg.
To convert % to mg/kg = Multiply the % by 10
For example, 1% lignocaine is 10mg/ml
Calculating Concentration of Epinephrine
Epinephrine concentrations are expressed as ratios. To calculate mg/ml
from a ratio you need to:
First, convert the ratio as a %: 1 in 100 is 1% and 1 in 1000 in 0.1%.
Second, multiply the % x 10 to get mg/ml.
For example, 1:1000 epinephrine is 1mg/ml.

69. Maximal Local Anesthesia Doses
 For each patient the dose varies and depends on the
area to be anesthetized, the vascularity of the tissues,
individual tolerance, and the technique of anesthesia.
 The lowest dose needed to provide effective
anesthesia should be administered.

70.  Reassurance
 Supine/Elevate legs for unconscious
patient
 100% oxygen
 Monitor vital signs
 Diazepam for seizures
 Call EMS
Treatment of Local Anesthesia & Epinephrine Toxicity

71. extracorporeal membrane oxygenation

72. Pathophysiology of Acute Adrenal Insufficiency
 Pathophysiology:
• patients are unable to produce normal levels of cortisol in situations
of stress secondary to trauma, infection, and surgery (normal
cortisol secretion is approximately 20 mg/day)
• This is RARE in the context of dental treatment/stress
 Classification
• Primary adrenal insufficiency (Addison’s disease)
• Secondary adrenal insufficiency (Hypopituitarism)
• Steroid-induced adrenal insufficiency (SLE, sarcoidosis, ulcerative colitis,
arthritis, pulmonary fibrosis, organ transplant)

73. Prevention of Acute Adrenal Insufficiency
 “Rule of two’s”: adrenocortical suppression should be suspected if a patient has
received 20 mg/day of cortisone (or its equivalent), for 2 weeks within the last 2
years
 Steroid supplementation: usually a 2- 4-fold increase in glucocorticosteroid
dosage on the day of surgery. RARELY indicated unless general anesthesia is
utilized. Stress Example Supplemental
Corticosteroid
Mild Singe dental extraction Double the dose
Moderate Multiple extractions Hydrocortisone 100 mg
Prednisone 20 mg
Dexamethasone 4 mg
Severe GA, major surgery Hydrocortisone 200 mg
Prednisone 40 mg
Dexamethasone 8 mg

74. Clinical Manifestations of Acute Adrenal Insufficiency
 Lethargy, fatigue, weakness, confusion
 Hypotension (<110 mm Hg systolic)
 Hypoglycemia (tachycardia, perspiration)
• Decreased gluconeogenesis
• Increased peripheral use of glucose secondary to lipolysis
 Syncope
 Anorexia
 Nausea, vomiting
 Pain in abdomen, lower back, legs
 Diarrhea, constipation
Mortality is secondary to hypoglycemia or hypotension

75. Treatment of Acute Adrenal Insufficiency
 Supine/Elevate legs for the unconscious patient
 BLS (Airway, Breathing, Circulation)
 100% oxygen
 Monitor VS
 100 mg hydrocortisone IM or IV (over 30 minutes)
 IV fluids for
• Hypotension
• Hypoglycemia (5% dextrose IV)
 Call EMS

76. Classification of Stroke (CVA)
Ischemic Hemorrhagic
Incidence 85% 15%
Mortality 30% 80%
Pathogene
sis
Occlusion of an artery by atherosclerosis,
thrombosis, or cerebral embolism
•HTN is a risk factor for thrombosis and
arthrosclerosis
Transient ischemic attack
•TIA or mini-stroke
•Transient cerebral occlusion due to HTN
•Focal neurologic deficits that last <24
hours (most last 2-10 minutes)
•Rupture of artery due to
aneurysm or hypertension
•Aneurysm: Bleeding onto the
surface of the brain
(subarachnoid hemorrhage)
•Hypertension: Bleeding into
the parenchyma of the brain
(intracerebral hemorrhage);
50% mortality
Onset •Atherosclerotic or thrombotic: gradual onset
(minutes, hours, days) of symptoms which are
preceded by TIAs
•Embolism: abrupt onset (seconds)
Abrupt onset (seconds)
FatahzadehM; et al; OOOOE 2006

77. Dental Considerations for Stroke
 Although hemorrhagic stroke is responsible for about 15%
of all strokes, it represents more of a potential risk to the
dental practitioner dealing with acutely anxious patients
and with potentially painful procedures
 Hypertension is the single greatest risk factor in the
development of all forms of stroke
 Ischemic stroke may be misdiagnosed as a migraine,
seizure or anxiety (Solenski NJ; Am Fam Phys 2004)
 Risk of hemorrhagic stroke increases 30% for every 10
mm Hg elevation of SBP above 160 mm Hg

78. Dental Considerations for Stroke
 Calcified atheroma (atherosclerotic plaque) at carotid bifurcation
 Duplex ultrasonic examination is required to evaluate for carotid stenosis
 The risk of stroke has yet to be determined (Mupparapu M, et al; JADA 2007)

79. Signs and Symptoms of Stroke
 Unilateral paralysis (face, arm, hand, leg)
 Muscle weakness
• Test: grip, dorsiflexion/plantar flexion of foot
 Numbness (face, arm, hand, leg)
 Language disturbance
• Aphasia (trouble understanding other’s speech, trouble writing or reading)
• Dysarthria (defective articulation)
 Ataxia
 Visual disturbance (blurred, diplopia)
 Vertigo
 Unconsciousness
 Nausea and vomiting
 Headache
 Elevated BP; variable HR (hemorrhagic)

80. Rapid Stroke Assessment
Cincinnati Prehospital Stroke Scale
 Facial droop (have patient show teeth or smile)
• Normal: both sides of face move equally
• Abnormal: one side of face does not move as well as the other side
 Arm drift (patient closes eyes and holds both arms straight out for 10 seconds)
• Normal: both arms move the same or both arms do not move at all
(other findings, such as pronator drift may be helpful
 Abnormal speech (have the patient say “you can’t teach an old dog
new tricks”)
• Normal: patient uses correct words with no slurring
• Abnormal: patient slurs words, uses wrong words, or is unable to speak

81. Differentiating Migraine with Aura Vs. TIA
Migraine with Aura TIA(Transient ischemic attack)
Occurrence Multiple previous episodes New event
Onset Gradual Sudden onset
Duration Short May last 24 hours
Progression Worsens and improves No pattern

82. Stroke Management
 Evaluate patient
• Symptoms resolve = TIA?
• Symptoms persist = CVA or TIA
 Call EMS – “Time is Brain”
 CPR
 100% oxygen 6-8 L/min
 Monitor VS
 Supine position with head and chest elevated slightly
• If CPR becomes necessary, patient is repositioned into the supine position
with feet elevated
 Avoid hypotonic fluids (D5W) and excessive fluid loading
• Preferred fluids: NS, Lactated Ringer’s, Ringer’s
• Consider insulin when blood glucose is >185 mg/dL (Jauch EC, et al; Circulation 2010)
 Transfer to hospital: recombinant tissue plasminogen activator (rtPA) indicated for ischemic stroke

83. A 25 year old male is to undergo removal of four
erupted third molars under local anesthesia. Six
cartridges of 2% lidocaine with 1:100,000
epinephrine is distributed equally over four
quadrants
Within a minute, the patient suddenly opens his
mouth widely, becomes non-responsive, and
elicits tonic-clonic seizures
 Differential diagnosis?
 Treatment?
Case #3

84. Differential Diagnosis of Seizures
 Most common in dental office
• Epilepsy (exacerbated by physical and emotional stress)
• Local anesthesia overdose
• Hypoglycemia
• Loss of consciousness
 Others
• Metabolic disorders (hypoglycemia, hypocalcemia, phelnyketonuria, alcohol and drug withdrawal)
• Cerebral tumors
• Congenital abnormalities (maternal infection, trauma, or hypoxia during delivery)
• CNS infections (bacterial meningitis)
• Head trauma
• Febrile convulsion (infants and children up to 5 years, >102ºF, non-CNS infection)
• Cerebrovascular insufficiency (cerebral arteriosclerosis)

85. Seizure Classification
 Partial (focal, local)
• Simple partial seizures
• Complex partial seizures
• Partial seizures evolving to secondarily generalized seizures
 Generalized (convulsive or nonconvulsive)
• Absence seizures (pet mal)
• Myoclonic seizures
• Tonic-clonic seizures (grand mal)
• Tonic seizures
• Atonic seizures

86. Differentiating Seizure Vs. TIA
Seizure TIA
Transient ischemic attack
Positive Motor Signs Yes No
Duration Shorter Longer
Postictal effects
(drowsiness, confusion,
nausea, headache)
Yes No
Tongue biting Yes (20-30%) No
Benbadis S; Epilepsy Behav 2009
Benbadis S; Am Fam Phys 2004

87. Treatment of Seizures
 Supine position with head turned to side
 Remove nearby objects
 Aspirate secretions
 Protect patient (loosen clothes, prevent tongue biting)
 100% oxygen
 BLS (maintain airway)
 Monitor vital signs
 Anticonvulsant medication (midazolam, diazepam)
 1 ampule of 50 ml of 50% dextrose (25 g) if the medical
history (i.e., diabetes) is unknown or if a glucose finger
stick cannot be performed
 Call EMS

88. A 27 year old male is scheduled for extraction
of two erupted 3rd molars under local
anesthesia
As topical anesthesia is applied, he becomes
visibly tense, short of breath with a respiratory
rate of 28 breaths per minute, and experiences
tingling in his fingers
 Differential diagnosis?
 Treatment?
Case #4

89. Shortness of Breath (Conscious Patient)
Supine position for comfort BLS
Oxygen, Vital signs
Review medical history
NEGATIVE
 Hyperventilation
 Foreign body aspiration
 (loss of tooth or instrument?)
POSITIVE
 Asthma
 Pulmonary edema

90. Aspiration of Primary Incisor

91. Aspiration Tooth #18

92. Aspiration
 Partial airway obstruction
• Coughing, choking, wheezing, shortness of breath, “crowing”
sound on inspiration, cyanosis
• More than 90% of patients are symptomatic within 1 hour
 Complete airway obstruction
• Inability to speak, breath, cough
• Cyanosis
• Universal sign for choking
 Most common location is the right bronchus (more vertical than left
bronchus)
 Retrieval: bronchoscopy, thoracotomy

93. Swallowed Hyrax Key

94. Swallowed Denture

95. Treatment of Objects Lost in Oropharynx
 Finger sweep
• Unconscious patient
• Supine position
 Reposition chair into reclined or Trendelenburg position
• May allow gravity to move object closer to the oral cavity where it
may become more visible and easier to retrieve
• Use forceps (Magill) to retrieve object

96. Treatment of Airway Obstruction
 A patient with partial airway obstruction who is capable of forceful
coughing and is breathing adequately should be left alone
 Treatment is indicated when a patient demonstrates poor air exchange
(“crowing”, absent voice sounds, cyanosis)
• Back blows (infant)
• Heimlich maneuver (conscious)
• Abdominal thrust (unconscious)
• Cricothyrotomy

97.  Wrap your arms around victim’s waist
 Make a fist; place the thumb side of your fist
against the abdomen slightly above the
navel and below the xiphoid
 Grasp your fist with the other hand
 Press your fist into the abdomen with a quick
inward and upward thrust
 The action is with the hands; the arms
do not press on the ribs
Obstructed Airway Management In Conscious Adult (Heimlich
Maneuver)

98. Obstructed Airway Management In Unconscious Adult
(Abdominal Thrusts)
 Victim positioned on back
 Kneel straddling the thighs
 Place one hand directly over the other in the
middle of the abdomen a little above the navel
 Press quickly into the abdomen and upward
toward the head
 Sweep mouth for debris
 Repeat if unsuccessful

99. Hyperventilation
 The most frequent cause of respiratory difficulty in the dental setting
 Acute anxiety is the most common predisposing factor
 Most common for patients 15 to 40 years of age
 Characteristics
 Neurologic: dizziness, tingling or numbness of fingers, toes, or lips (i.e.,
respiratory alkalosis, hypocarbia, hypocapnea), syncope is rare
 Respiratory: increased rate and depth of breaths (hyperpnea), feeling of
shortness of breath, chest pain, xerostomia
 Cardiovascular: palpitations, tachycardia, elevated BP
, precordial pain
 Musculoskeletal: myalgia, muscle spasm, tremor, tetany
 Psychologic: anxiety, tension, nightmares

100. Treatment of Hyperventilation
 Upright position
 Reassure and calm patient
 Slow deep breaths
 Breathing in bag
 Monitor vital signs; BLS rarely required
 Diazepam or midazolam IV or IM

101. Pathophysiology of Asthma
 Chronic inflammatory respiratory disease in which IgE sensitizes mast cells to
degranulate resulting in
• Airway inflammation
• Bronchoconstriction
• Mucous plugging (obstruction)
 Attacks provoked by
• Allergens (most common)
• Upper respiratory tact infections
• Exercise
• Cold air
• Highly emotional states such as anxiety, stress and nervousness
• Medications (salicylates, NSAIDS, beta-blockers)

102. Clinical Presentation of Asthma
Mild to Moderate
 Wheezing (audible with or without stethoscope)
 Dyspnea (i.e., labored breathing)
 Tachycardia
 Coughing
 Anxiety
Severe
 Intense dyspnea, flaring of the nostrils and use of accessory muscles of respiration
 Cyanosis of mucous membranes and nail beds
 Minimal breath sounds on auscultation
 Difficulty speaking
 Flushing of the face
 Extreme anxiety
 Mental confusion
 Diaphoresis

103. Perioperative Management of Asthma
 Well-controlled asthma does not pose a significant risk
 Schedule appointment in late morning or late afternoon to minimize risk of attack
 Patient’s own metered-dose inhaler (MDI) bronchodilator should be on hand at
each visit
 Anxiety may be a trigger
• Premedicate with antiasthma medication
• Stress management techniques
 Nitrous oxide is NOT a respiratory depressant nor an irritation to the
tracheobronchial tree
 Promethazine and diphenhydramine are sedatives and antihistamines
Steibacher DM, et al. The dental patient with asthma: an update and oral health considerations JADA 2001; 132: 1229

104. Perioperative Management of Asthma
 Avoid opiates (meperidine)
• Respiratory depression
• Induces histamine release
 Avoid postoperative aspirin and NSAIDs
• Up to 20% of patients with asthma may experience severe
exacerbations (Steinbacher DM, et al; JADA 2001)
• Thought to be related to the inhibition of the enzyme cyclo-
oxygenase which mediates conversion of arachidonic acid to
prostaglandins (a mediator of bronchodilation)
• Acetominophen may be used

105. Treatment of Acute Asthma
 Upright position for comfort
 BLS
 Monitor vital signs and blood oxygenation if available (Pulse Ox)
 100% oxygen
β2 agonist: MDI or nebulizer short-acting bronchodilator
(albuterol, metaproterenol)
β2 agonist: Epinephrine 0.3 ml (1:1000 concentration) SC or IM

106. Treatment of Acute Asthma
Systemic Corticosteroids
 Cortisone 100 mg IV
 Hydrocortisone 250 mg IV
 Methylprednisolone 1-1.5 mg/kg IV
 Dexamethasone 0.1-0.2 mg/kg IV
 Prednisone 1-1.5 mg/kg oral
Other
 Methylxanthines (Aminophylline)
 Anticholinergics (Ipratropium)
 Magnesium sulfate
 Call EMS

107. Bronchodilator Administration
Metered dose inhaler (MDI) Nebulizer

108. Methylxanthines
 Types
• Aminophylline (IV)
• Theophylline (oral)
 Smooth muscle relaxation of airways by inhibition of
phosphodiesterase
 Aminophylline 5 mg/kg IV over 30 minutes
 Questionable efficacy for acute attack due to narrow therapeutic
range and weak bronchodilating effect
 Useful in combination with other agents (β2 agonists, steroids)

109. Long-Term Treatment & Prevention of Asthma
 MDI long-acting β2 agonist bronchodilator (salmeterol)
 Inhaled corticosteroids (beclomethasone)
• Anti-inflammatory (inhibits cytokine production, reverses β2
downregulation, suppresses recruitment of airway eosinophils)
• Used when symptoms are more persistent and short-acting β2
agonist alone is ineffective
• Systemic side effects are rare
 Systemic corticosteroids (methylprednisolone, prednisone,
prednisolone)
• Local side effects with long-term use (dysphonia)

110. Long-Term Treatment & Prevention of Asthma
 Cromones
• Cromolyn is a mast cell stabilizer
• Nedocromil inhibits activation and release of mediators from
eosinophils
 Leukotriene antagonists
• Inhibits bronchoconstriction
 Anticholinergics (ipratropium bromide)
• Competitive inhibition of muscarinic cholinergic receptors
• Some patients respond well while others do not
 Methylxanthines

111. A 30 year old male is anesthetized with
procaine for extraction of a wisdom tooth
After 15 minutes he develops erythema,
itching and hives
 What systemic effects should you watch for?
 Treatment?
Case #5

112. Allergy
Signs and symptoms
• Hives
• Urticaria (smooth, slightly elevated patches of skin)
• Pruritus (itching)
• Erythema
• Facial flushing
• Nausea and vomiting
Treatment
• Monitor vital signs for systemic involvement (anaphylactic shock)
• Diphenhydramine

113. Anaphylaxis
 Signs and symptoms
• Same as allergy
• Respiratory: wheezing, laryngospasm, dyspnea, stridor, cyanosis
• Cardiovascular: hypotension, tachycardia, arrhythmia
 Classification
• One organ system = Localize anaphylaxis (i.e., bronchial
asthma)
• Generalized (systemic) = Anaphylactic shock (i.e., hypotension)

114. Treatment of Anaphylaxis
 Supine/Elevate legs for unconscious patient
 BLS
 100% oxygen
 Monitor vital signs
 Call EMS
 Medications
• Bronchodilator MDI (wheezing)
• Epinephrine 0.3 mL of 1:1000 (wheezing or hypotension) Relatively
contraindicated in patients, CAD, hypertension, and tachydysrhythmias
• Route depends on severity (SC, IM, IL, IV)
• Diphenhydramine
• Corticosteroid

115.  What are your concerns?
 What precautions do you need to take?
 Neurological findings?
A 22 year old female fell as she approached the front desk to make a
follow-up appointment
Case #6

116. Evaluation of Trauma Patient
 Assessment of ABC
 Vital Signs
 Neurologic status (Glascow Coma Scale)
• Eye opening (spontaneously, to speech, to pain, none)
• Motor response (obeys, localized pain, withdraws from pain, flexion to pain, extension to pain,
none)
• Verbal response (oriented, confused, inappropriate, incomprehensible, none)
 Neurologic exam
• AVPU
• Alert
• Responds to vocal stimuli
• Responds to painful stimuli Unresponsive
• Pupil reaction to light?
 Neck should be examined for deformity, edema, ecchymosis, muscle spasm, and tenderness

117.  Where do you continue treatment?
 Where is patient to be discharged?
• Home (is escort available?)
• M.D.
• Hospital
Post-Emergency Considerations

118.  Be prepared
 Be alert
 Anticipate
 Be calm! Remember to check your pulse first, then the
patient’s pulse
 Although the tenet of emergency medicine is “when in
doubt, do” remember that above all else “do no harm”
Conclusion (“Pearls”)

119. What Medical Emergencies Are Preventable?
a) Vasovagal syncope
b) Asthma
c) Seizures
d) Hyperventilation
e) Allergic reaction
f) Cardiovascular emergencies (MI, angina)
g) Postural hypotension
h) Pulmonary edema
i) Stroke
j) Acute adrenal insufficiency

120. Preventable
 Conditions induced by stress
• Vasovagal syncope
• Hyperventilation
• Acute adrenal insufficiency
 Postural hypotension
May Not Be Preventable
 Conditions exacerbated by stress
• Cardiovascular emergencies (MI,
angina)
• Asthma
• Seizures (epilepsy)
• Pulmonary edema
• Hemorrhagic stroke
 MI
 Allergic reaction
 Occlusive stroke
What Medical Emergencies Are Preventable?

121. EMERGENCY DRUG KITS
MODULE ONE- Basic emergency kit (critical drugs & equipments)
MODULE TWO – non critical drugs & equipment
MODULE THREE – advanced cardiac life support
MODULE FOUR – antidotal drugs

122. EMERGENCY DRUG KITS

123. MODULE 1- Basic emergency kit
(critical drugs & equipment)
Injectable drugs
1. Epinephrine
2. Anti-histamine
Non-injectable drugs
1. Oxygen
2. Vasodialators
Emergency equipment
1. Oxygen delivery system
2. Suction & suction tips
3. Tourniquets
4. syringes

125. MODULE 2 (noncritical secondary emergency
drugs & equipment)
Secondary Injectable drugs
1. Anticonvulsaunt
2. Analgesics
3. Vasopressor
4. Antihypoglycemics
5. Corticosteroids
6. Antihypertensive
7. anticholinergic

126. Non-injectable drugs
1. Respiratory stimulant
2. Antihypoglycemic
3. bronchodilators
Emergency equipment
1. Device for cricothyrotomy
2. Artificial airways
3. Laryngoscope & endotracheal tubes
MODULE 2 (noncritical secondary emergency
drugs & equipment)

127. MODULE 3 – (ACLS –Essential drugs)
1. Epinephrine
2. Oxygen
3. Lidocaine
4. Atropine
5. Dopamine
6. Morphine sulfate
7. Verapamil

128. MODULE 4 : Antidotal drugs
Narcotic antagonists
Benzodiazepines
Antiemergence
delerium drug
Vasodilator

129. Questions?

130. • Fasting blood glucose level of 180 mg/dl is a cut-off
point for any selective dental extraction.
• However, Random blood glucose level of 234 mg/dl
(13 mmol/l) is a cut-off point for an emergency tooth
extraction.
• Tightly controlled diabetic patients (blood glucose
level below 70 mg/dl) are susceptible to
hypoglycemia.