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Medical emergencies in Dental Practice

Covers management of medical emergencies in dental practice.

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Medical emergencies in Dental Practice

  1. 1. Medical Emergencies in Dental Practice Dr. Vibhuti Kaul
  2. 2.  UNCONSCIOUSNESS • VASODEPRESSOR SYNCOPE • POSTURAL HYPOTENSION • ACUTE ADRENAL INSUFFICIENCY  RESPIRATORY DISTRESS • ASTHMA • HYPERVENTILATION • AIRWAY OBSTRUCTION • HEART FAILURE  ALTERED CONSCIOUSNESS • DIABETES MELLITUS • THYROID GLAND DYSFUNCTION • CEREBRO VASCULAR ACCIDENT  SEIZURES  DRUG RELATED EMERGENCIES • DRUG OVERDOSE • ALLERGY  CHEST PAIN • ANGINA PECTORIS • ACUTE MYOCARDIAL INFARCTION
  3. 3. “When you prepare for emergencies, they cease to exist!” Malamed
  4. 4. INTRODUCTION • Medical emergencies can and do occur in the dental office. The dental office environment is not immune to the occurrence of potentially life- threatening situations . The overwhelming majority of emergencies encountered are precipitated by the increased stress that is so often present in the patient in the dental environment. Increased stress can result from fear and anxiety or inadequate pain control.
  5. 5. The concept of ‘‘how healthy is the patient,’’ otherwise termed ‘‘risk assessment,’’ is key in determining the likelihood of complications. The higher the ASA class, the more at-risk the patient is both from a surgical and anesthetic perspective. • ASA Class I. A normal healthy patient • ASA Class II. A patient with mild systemic disease • ASA Class III. A patient with severe systemic disease • ASA Class IV. A patient with an incapacitating systemic disease that is constant threat to life • ASA Class V-A moribund patient not expected to survive 24 hrs with or without operation • ASA E- Emergency operation of any variety
  6. 6. Urgencies vs Emergencies • Urgency: a problem that requires prompt response; it is not immediately life threatening but could become so if not resolved promptly – Syncope – Hypoglycemia – Seizure – Asthmatic attack – Hyperventilation – Angina – Mild allergic reaction • Emergency: a problem that is immediately life threatening and requires immediate action – Cardiac arrest – Anaphylaxis – Obstructed airway 9
  7. 7. Medical Emergencies in the Dental Office • Hyperventilation 29% • Seizures 20% • Hypoglycemia 14% • Vasodepressor syncope 11% • Postural hypotension 7% • Asthma 7% • Angina 5% • Allergy 5%
  8. 8. Preparation • Staff training -Basic Life support training -Training in recognition and management of specific emergency situation -emergency fire drills
  9. 9. • Office preparation -Posting emergency assistance number -Stocking emergency drugs and equipments
  10. 10. BASIC LIFE SUPPORT • “Single important step in preparation for medical emergencies” • In all emergency situations without exception, initial management will always entail the application as needed of the steps of basic life support. • Drug therapy is always relegated to a secondary role.
  11. 11. • Step I- Assessment of consciousness -Importance? -Three criteria Lack of response to sensory stimulation Loss of protective reflexes An inability to maintain patent airway
  12. 12. • Step 2-Call for help
  13. 13. Step 3- position the patient
  14. 14. • Trendelenberg position should be avoided- when? One situation in which modification is required -pregnancy
  15. 15. Step 4-Assess and open airway
  16. 16. Head tilt- chin lift
  17. 17. Jaw thrust
  18. 18. Step 5-Assess airway patency and breathing
  19. 19. CAUSES OF PARTIAL AIRWAY OBSTRUCTION SOUND HEARD CAUSE MANAGEMENT Snoring Hypopharyngeal head tilt obstruction by tongue gurgling foreign body suction airway wheezing bronchial administer obstruction bronchodilator
  20. 20. Removal of foreign material • Before attempting to perform artificial ventilation • Presence of liquid in hypopharynx- produces gurgling sound • Most common foreign materials- saliva blood water or vomitus. • If present in large amount- complete obstruction • If particulate material enter trachea-create complete obstruction of respiratory track- asphyxiation-death
  21. 21. HEIMLICH MANEUVER
  22. 22. • Once airway patency and exchange has been established –loosen the constricting clothing • Vital signs should be monitored and if available oxygen is administered.
  23. 23. Step 6-artificial ventilation if needed • If respiratory arrest present or spontaneous ventilation deemed inadequate-ventilate the victim • Three ways -exhaled air ventilation -atmospheric air ventilation -oxygen enriched ventilation
  24. 24. Exhaled air ventilation • Two methods -mouth to mouth ventilation -mouth to nose ventilation
  25. 25. Mouth to mouth ventilation
  26. 26. Mouth to nose ventilation
  27. 27. • The first ventilatory cycle—two full breaths- allowing 1 to 1.5 seconds per inspiration –with rescuer taking a breath after each ventilation • Exhalation occur passively • Artificial ventilation is repeated -in adult-once every 5 seconds( 12 times per minute) -in child-once every 4 seconds(15 times per minute) -in infant- once every 3 seconds(20 times per minute)
  28. 28. • Adequacy of ventilatory efforts gauged by -feeling air escape as victim exhales -seeing rise and fall of patient’s chest(more important) • Volume of air required to produce chest expansion-800ml • Disadvantage of artificial ventilation-gastric distension
  29. 29. Atmospheric air ventilation
  30. 30. Enriched oxygen ventilation
  31. 31. Step -7-Assess circulation • After establishing a patent airway –adequacy of patient’s circulation is determined • Monitor patient’s heart rate or blood pressure • In conscious patients- Brachial artery , radial artery and carotid artery in neck • In unconscious patients- large artery should be located and palpated • Femoral artery and carotid artery • Carotid artery preferred
  32. 32. How to locate the carotid artery?
  33. 33. Step 8 • Patent airway + adequate circulation– definite management • If not - activate emergency medical system - location of emergency - no. of telephone from which call is made - what happened (heart attack, seizure , accident) - how many persons need help - condition of victim - what aid is being given - any other information requested
  34. 34. Step 9- External chest compression • Rhythmic application of pressure over lower half of adult sternum
  35. 35. Location of pressure point
  36. 36. Hand position
  37. 37. Application of pressure • Sternous • Improperly performed – ineffective as well as exhausting • Points to remember for effective ECC with minimum fatigue -shoulder of rescuer must be directly above the sternum -elbow of rescuer should be locked (straight) not bent
  38. 38. • Sternum is depressed 1 and half inches (3.8 to 5 cm) • Rescuer allows weight of his or her body to compress the sternum • Movement of rescuer occur only at hip-back and forth rocking motion • Compressions- regular , smooth and uninterrupted • heel should not be removed during relaxation-though pressure should be released completely.
  39. 39. Rate of compression • 100 per minute if possible • If one rescuer-Ratio of chest compression to artificial ventilation-30:2(earlier 15:2) allowing 1 to 1.5 seconds per ventilation • If two rescuer-5:1 with a pause of 1 to 1.5 seconds for ventilation
  40. 40. Evaluation of effectiveness • Colour of skin and mucous membrane • Carotid pulse • Respiratory movements • Pupils of eye
  41. 41. COMMON MEDICAL EMERGENCIES ENCOUNTERED IN DENTAL PRACTICE
  42. 42. UNCONSCIOUSNESS 3 factors when present increase the chances that loss of consciousness occur. These are: • Stress • Impaired physical status: ASA III or ASA IV • Administration of drugs (analgesics, antianxiety drugs, local anesthetics)
  43. 43. Common causes of unconsciousness Vasodepressor syncope Most common Drug administration/ingestion Common Orthostatic hypotension Less common epilepsy Less common Hypoglycemic reaction Less common Acute adrenal insufficiency Rare Acute allergic reaction Rare Acute myocardial infarction Rare Cerebrovascular accident Rare Hyperglycemic reaction Rare Hyperventilation Rare
  44. 44. CLASSIFICATION OF CAUSES OF UNCONSCIOUSNESS BY MECHANISM Mechanism Clinical example Inadequate delivery of blood or oxygen to brain Acute adrenal insufficiency Orthostatic hypotension Vasodepressor syncope heart disease, dysrrhythmias hyperventilation Occlusion of internal carotid artery Systemic or local metabolic deficiencies Acute allergic reactions Drug ingestion and administration: - Nitrites and nitrates - Diuretics - Sedatives – narcotics - LA Hyperglycemia Hyperventilation Hypoglycemia Direct or reflex effects on nervous system Cerebrovascular accidents Convulsive episodes Psychic mechanisms Emotional disturbances Hyperventilation Vasodepressor syncope
  45. 45. CLINICAL MANIFESTATIONS • Incapable of responding to sensory stimulation • Lost protective reflexes • Lack of ability to maintain patent airways
  46. 46. SYNCOPE • It is defined as sudden, transient loss of consciousness that is usually secondary to period of transient ischemia. • Synonyms for vasodepressor Syncope: faint, Swoon, Vasovagal Syncope, Neurogenic Syncope
  47. 47. PREDISPOSING FACTORS Psychogenic factors • Fright • Anxiety • Emotional stress • Pain • Sight of blood or syringe
  48. 48. Nonpsychogenic factors • Sitting in upright position or standing • Hunger • Exhaustion • Poor physical condition • Hot, humid environment • Age between 16 to 35 year • Males
  49. 49. Pathophysiology of Syncope • Lack of oxygen and blood to the brain • Lack of glucose to the brain
  50. 50. Causes of Syncope • Cardiac • Peripheral vascular • Cerebrovascular • Hyperventilation • Hypoglycemia • Seizures
  51. 51. CLINICAL MANIFESTATIONS Presyncope : • Early : • feeling of warmth • ashen gray skin • heavy perspiration • feeling bad or faint • nausea • blood pressure approximately at baseline • tachycardia
  52. 52. late : • pupillary dilatation • yawning • hyperpnea • coldness in hand and feet • hypotension • bradycardia • visual disturbances • dizziness • loss of consciousness
  53. 53. Syncope • irregular, gasping and jerky breathing • or it may cease entirely (respiratory arrest/apnea) • dilated pupils • convulsive movements • bradycardia • low BP • weak and thready pulse • generalized muscle relaxation • fecal incontinence
  54. 54. Postsyncope : • Pallor • Nausea • Weakness and Sweating • Mental confusion and disorientation which may persist for 24 hours
  55. 55. • Cerebral blood flow required for maintaining consciousness is about 30ml of blood per 100 gm of brain tissue per minute. • Brain weighs about 1360 gms. • Normal value of cerebral blood flow per minute is 50 to 55 ml per 100 gm per minute. • So when this decreases, syncope occurs!
  56. 56. MANAGEMENT OF VASODEPRESSOR SYNCOPE Assess consciousness • Activate office emergency team • Put patient in supine position with feet elevated • Assess and open airway and assess circulation* • Activate EMS if recovery is not immediate • Administer oxygen • Monitor vital signs • Provide definite management of unconsciousness: • Loosening of binding clothes • Aromatic ammonia • Atropine, if bradycardia persists • Maintain composure • Postsyncopal recovery delayed recovery • Arrange escort home activate EMS
  57. 57. POSTURAL HYPOTENSION • Second leading cause of unconsciousness • Results from failure of baroreceptor reflex mediated increase in peripheral vascular resistance in response to positional changes. • Infrequently associated with fear and anxiety.
  58. 58. Predisposing factors Administration and ingestion of drugs • -antihypertensives esp sodium depleting diuretics, Ca channel blockers, ganglion blocking agents • -phenothiazines like chlorpromazine, thioridazine • -tricyclic antidepressants like doxipen, amitryptaline, imipramine • -narcotics like morphine and mepiridine • -antiparkinsonism drugs like levodopa • -Sedatives and tranquilizers • N2O sedation,
  59. 59. • Age – more chances with increasing age • Prolonged recumbency and convalescence (as seen in long dental appointments) • Inadequate postural reflex • Pregnancy • Varicose veins in legs • Addison’s disease • Physical exhaustion, fatigue and starvation • Chronic postural hypotension
  60. 60. PATHOPHYSIOLOGY
  61. 61. CLINICAL CRITERIA FOR POSTURAL HYPOTENSION • Symptoms develop on standing without any prodromal syndromes • Decrease in standing systolic BP atleast 25mm Hg • Decrease in standing diastolic BP atleast 10mm Hg. • No postrecovery signs and symptoms.
  62. 62. CARDIOVASCULAR RESPONSE TO POSITIONAL CHANGE Change in response to sudden elevation from supine to elevated position Normal Postural hypotension Systolic BP + 10 mm Hg - Decrease of >25mm Hg Diastolic BP Increase 10 to 20mm Hg Decrease of >10mmHg Heart rate 5 – 20 beats per min above baseline At baseline or>30 beats per minute above baseline
  63. 63. Dental therapy considerations • Patients should be cautioned against rising too rapidly from supine or semisupine position. • Patient should be slowly returned to erect position at conclusion of therapy. • Two or three positional changes over a period of minute or two to reach the upright position.
  64. 64. ACUTE ADRENAL INSUFFICIENCY PREDISPOSING FACTORS • Addison’s disease • Secondary insufficiency • Stress
  65. 65. Rule of Two: • Adrenocortical suppression should be suspected if a patient has received Glucocorticoid therapy : • In a dose of 20 mg or more of cortisone or its equivalent daily • Via the oral or parentral route for a continuous period of 2 weeks or longer • Within two years of dental therapy
  66. 66. CLINICAL MANIFESTATIONS • Weakness and fatigue • Anorexia • Weight loss • Hyperpigmentation • Hypotension • Hypoglycemia • Nausea, vomiting • Syncope • Lethargy • Confusion(marked most notably) • Psychosis
  67. 67. DENTAL THERAPY CONSIDERATIONS • 1. Glucocorticosteroid coverage • With milder stress like single dental extraction, use double daily dose. • In moderate stress like surgery under local anaesthesia, several dental extractions, use Hydrocortisone 100mg or prednisolone 20 mg or Dexamethasone 4 mg daily. • Severe stress like in severe trauma use Hydrocortisone 200mg, or prednisolone 40 mg or Dexamethasone 8 mg daily.
  68. 68. MANAGEMENT • Terminate dental care • Position patient comfortably if asymptomatic • Supine with feet elevated, if symptomatic • Monitor vital signs • Summon medical assistance • Administer oxygen • Administer glucocorticoid • Additional management: provide Basic Life Support as needed • Provide oxygen as needed • Maintain iv line
  69. 69. UNCONSCIOUSNESS – DIFFERENTIAL DIAGNOSIS child Teens to mid 30 Over 40 Hypoglycaemia stress Cardiovascular disease Epilepsy hypoglycemia epilepsy
  70. 70. Heart rate and blood pressure during unconsciousness Cause of unconsciousness Heart rate Blood Pressure Hypo/hyperglycemia increases Decreases Vasodepressor syncope decreases Decreases Postural hypotension baseline Decreases CV accident variable Increases dysrhythmias variable decreases
  71. 71. DIABETES MELLITUS • Diabetes mellitus (DM) is a disease of glucose, fat, and protein metabolism resulting from impaired insulin secretion, varying degrees of insulin resistance, or both. • Stress increases body resistance to insulin and so patients may develop hyperglycemia during treatment. • Type 2 Diabetics are less prone to complications that develop during treatment as compared to type 1 which are more prone to ketosis.
  72. 72. DENTAL THERAPY CONSIDERATIONS • Advise the patients to take usual insulin dose and to eat normal breakfast before treatment. • Schedule dental appointments early in the day to minimize the episodes of hypoglycemia. • Dental appointment scheduling should avoid appointments that will overlap with or prevent scheduled meals.
  73. 73. • For prolonged procedures, especially if they encroach on mealtime, intraoperative blood glucose evaluation is advisable. • Use of LA without epinephrine • Use of shorter acting LAs (eg Mepivacaine plain versus longer acting eg Bupivacaine with epinephrine will minimize postoperative eating impairment.
  74. 74. Hyperglycemia Diagnostic clues: • Florid face, dry, warm skin • Kussmaul’s respiration • Fruity odour • Rapid, weak pulse • normal to low BP • Rapid HR
  75. 75. Management of hyperglycemic patient (unconscious patient) • Terminate dental procedure • Position the patient • BLS • Summon medical assistance • IV infusion (5% dextrose and water) • administer oxygen • If diagnosis in doubt, administer glucose paste • Transport to hospital
  76. 76. Hypoglycemia Diagnostic clues: • Sweating, tachycardia (sympathetic overactivity) • Weakness, dizziness • Pale, moist skin ,and cold skin (in contrast to hyperglycemia) • Shallow respiration • Headache • Altered consciousness
  77. 77. Management (conscious patient) • Terminate dental procedure • Position the patient • BLS • Administer 15 gms of oral carbohydrate • No improvement – administer parentral carbohydrate or glucagon if available or intravenous dextrose. • Observe patient atleast for 1 hour before discharging
  78. 78. Hypoglycemia (unconscious patient) • Terminate dental procedure • Position patient in supine patient • BLS • Summon medical assistance • Definitive management (50%dextrose iv, 1mg glucagon im, transmucosal sugar). If none of the two is available, 0.5mg dose of 1:1000 conc epinephrine SC or IM every 15 minutes
  79. 79. • The well-controlled diabetic is probably at no greater risk of postoperative infection than is the nondiabetic. Therefore, routine dentoalveolar surgical procedures in well- controlled diabetics (HbA1c 8%) do not require prophylactic antibiotics. However, when surgery is necessary in the poorly controlled diabetic, prophylactic antibiotics should be considered.
  80. 80. RESPIRATORY DISTRESS
  81. 81. AIRWAY OBSTRUCTION • Sit down, four handed dentistry • Most common cause – Tongue • Foreign bodies
  82. 82. Preventive measures • Rubber dam • Oral packing • Chair position • Suction • Magill intubation forceps • Ligature
  83. 83. CAUSES OF PARTIAL AIRWAY OBSTRUCTION SOUND HEARD CAUSE MANAGEMENT Snoring Hypopharyngeal head tilt obstruction by tongue gurgling foreign body suction airway wheezing bronchial administer obstruction bronchodilator
  84. 84. COMPLETE UPPER AIRWAY OBSTRUCTION PHASE SIGNS AND SYMPTOMS • First phase universal choking sign (1 to 3 min) struggling, paradoxical respiration • Second phase loss of consciousness, (2 to 5 min) decreased respiration, BP and pulse • Third phase coma, absent vital signs, (4 to 5 min) dilated pupils
  85. 85. DENTAL CONSIDERATIONS • Do not permit patient to sit up • Place chair in more reclined position (Trendelenberg position) and try to remove object with Magill intubation forceps. • Left lateral decubitus position with head down. • Radiographs . • Consult the doctor.
  86. 86. If objects enter into the trachea: • Place the patient in left lateral decubitus position • Encourage patient to cough • • Object is retrieved not retrieved, consult with radiologist • Initiate medical consultation appropriate radiograph prior to discharge perform endoscopy
  87. 87. • RECOMMENDED SEQUENCE FOR REMOVING AIRWAY OBSTRUCTION For adult conscious victim with obstructed airway -identify complete airway obstruction- ask ‘are u choking?’ -identify yourself as someone who can help victim-say ‘I can help you’ -Apply Heimlich maneuver until foreign body is expelled or victim become unconscious -have medical evaluation of patient before discharging
  88. 88. For adult unconscious victim with obstructed airway • Assess responsiveness • Position patient in supine patient with feet elevated • Call for help • Open airway (head tilt – chin lift) • Assess breathing (look, listen and feel) • Attempt to ventilate. If unsuccessful • Reposition head and reattempt to ventilate • Activate EMS system • Perform Heimlich manoeuvre • Perform foreign body check: finger sweep • Surgical management, if above procedures are ineffective
  89. 89. HYPERVENTILATION • It is defined as ventilation in excess of that required to maintain normal blood PO2 and PCO2. • Produced by increase in either the frequency or depth of respiration or a combination of the two.
  90. 90. Hyperventilation Causes • Anxiety – Most common • Metabolic conditions – Pain – Metabolic acidosis – Drug intoxication – Hypercapnia – CNS disorders
  91. 91. Predisposing Factors • Anxiety – Most common • Age – 15 - 40 years of age – No sex difference
  92. 92. Pathophysiology • Increased respiratory rate causes: – Acute decrease in PaCO2 and rise in blood pH • Cerebral vessels constrict Unconscious • Decreased PaCO2 depresses Apnea respiratory drive • Increased coronary artery resistance –pain in chest – Disturbed Ca metabolism (due to change in pH of blood) ionized Ca in blood decreases tingling, parasthesia, tetany, convulsions.
  93. 93. CLINICAL MANIFESTATIONS • CV – palpitations, tachycardia, precordial pain • Neurologic – dizziness, lightheadedness, numbness and tingling of extremities • Respiratory – shortness of breath, chest pain • GI – epigastric pain • Musculoskeletal – muscle pain and cramps, stiffness, tetany • Psychologic – tension, anxiety, nightmares
  94. 94. Management • Terminate procedure • Position patient (upright) • Calm patient • Correct respiratory alkalosis (breathe in gaseous mixture of 7% CO2 and 93% O2) • Rebreathing bag (exhaled air) • Drug management – 10 to15 mg diazepam or 3 to 5 mg Midazolam IV
  95. 95. ASTHMA • Disease characterized by an increased responsiveness of trachea and bronchi to various stimuli and manifested by widespread narrowing of airways that changes in severity either spontaneously or as a result of therapy. American Thoracic society
  96. 96. Can be: • Extrinsic Asthma • Intrinsic Asthma • Status Asthmaticus
  97. 97. SIGNS AND SYMPTOMS OF ACUTE ASTHMA • Feeling of chest congestion • Cough with or without sputum production • Wheezing • Dyspnea • Use of accessory muscles of respiration • Tachypnea • BP – baseline to elevated • HR increased • Diaphoresis/ sweating • Confusion • Cyanosis • Supraclavicular and intercostal retraction • Nasal flaring
  98. 98. DENTAL THERAPY CONSIDERATIONS • Proper stress reduction protocol. • No CI to use of any conscious sedation technique except for drugs like barbiturates and narcotics especially mepiridine which can precipitate bronchospasm in these patients. • Inhalation anaesthetics like ether that irritate respiratory mucosa are capable of inducing bronchospasm in these patients. However N2O is safe for these patients. • Drugs like NSAIDS and penicillin must be avoided. • Sulphating agents such as Sodium metabisulphite used as antioxidant for epinephrine in LA can provoke bronchospasm and should be avoided.
  99. 99. MANAGEMENT OF ACUTE ASTHAMATIC ATTACK • Terminate dental procedure • • Position the patient in sitting position with arms thrown forwards • • Remove dental materials from patient’s mouth • Calm the patient • Basic life support • Administer bronchodilator via inhalation* • Episode terminates episode continues • • Subsequent dental care administer oxygen • Administer parentral medications • Discharge patient hospitalize patients
  100. 100. Dosage of injectable epinephrine Patient Age Range Dose (mL) Epinephrine 1:1,000 (mL) Adult > 9 years 1.0 0.3 Child 1 through 8 years 0.5 0.15 Infant <1 year 0.25 0.075
  101. 101. CHEST PAIN Common cardiac causes: • Angina pectoris • Myocardial infarction.
  102. 102. Non cardiac causes • Hiatus hernia • Oesophageal spasm • Peptic ulcer • Cholecystitis • Pericarditis.
  103. 103. Major risk factors of heart disease Factors that can’t be changed: • Heredity • Sex • Age
  104. 104. Factors that can be changed: • Tobacco chewing • High blood pressure • High blood cholesterol levels • Diabetes
  105. 105. ANGINA PECTORIS Angina is a latin word meaning a spasmodic, cramp like , choking feeling, or suffocating pain. It can be • Stable angina/chronic/classic/exhertional angina • Unstable angina/ crescendo angina, pre infarction angina • Prinzmetal angina/ vasoplastic angina / variant angina
  106. 106. COMPARISON OF ANGINAL SYNDROMES Anginal syndrome synonyms Predis. factors duration Response to nitroglycerin Stable Chronic, classic, exertional Stress, exertion, cold weather 1 to 15 min Good Variant Prinzmetal’s , vasoplastic Coronary artery spasm variable Good Unstable Pre infarction, crescendo No factor Upto 30 min questionable
  107. 107. Angina Pectoris • Unstable angina pectoris – Indicative of progressive coronary artery disease – Indistinguishable from MI – Requires admission to “rule out” MI • Enzymes - CPK-MB, LDH, Troponin I and T • Clinical history
  108. 108. Angina Pectoris • Causes: – Coronary artery atherosclerosis – Coronary artery spasm – Multiple other cardiac and pulmonary etiologies: • Aortic stenosis, cardiomyopathy, pulmonary hypertension or infarction, myocardial disease, pericarditis, mitral valve prolapse, aortic dissection
  109. 109. Angina Pectoris • May occur in the absence of heart disease or coronary artery abnormalities (Syndrome X) • Uncommon in premenopausal females unless they have diabetes, hypertension or hyperlipidemia
  110. 110. Angina Pectoris • Clinical characteristics – Poorly localized pain • Usually retrosternal but may occur anywhere from lower jaw to umbilicus – Brief duration • 2-10 minutes – Moderate intensity pain described as squeezing, oppressive, burning or heavy
  111. 111. Angina Pectoris • Clinical characteristics – Precipitated by: • Emotional distress • Physical exertion • Heavy meals • Cold • Walking up stairs or hills – Exacerbated by: • Recumbency
  112. 112. Angina Pectoris – Excluded if: • Pain localized with one finger • Lasts less than 30 seconds or longer than 30 minutes • Pain described as sticking, jabbing, throbbing or constantly severe
  113. 113. Angina Pectoris • Treatment – Stop procedure – Position patient to comfort – Oxygen 2-3 L per NC or face mask – Nitroglycerin 0.4 mg SL • Repeat for 5 minutes • If no response, assume MI or unstable angina • Activate EMS and transfer to hospital
  114. 114. Angina Pectoris • Diagnostic approach – Nitroglycerin • Normally relieves pain in 3 minutes or less • Failure to relieve pain after 10 minutes evidence against angina • Failure to relieve pain indicates either unstable angina or myocardial infarction
  115. 115. Angina Pectoris • Function of nitroglycerin – Dilates coronary arteries to increase blood flow and improve oxygen delivery to cardiac tissue – Platelet disaggregation
  116. 116. Angina Pectoris • Dental treatment – Early morning appointments – Short appointments – Stress reduction protocols – Supplemental oxygen – Adequate pain control
  117. 117. • LA containing vasoconstrictor can be used with proper technique. • Max safe dose of epinephrine for cardiac patients is 0.04 mg which is equivalent to 1 cartridge of 1:50000 conc, 2 cartridges of 1:100000 and 4 cartridges of 1:200000 conc.
  118. 118. Myocardial Infarction • It is a clinical syndrome resulting from deficient coronary artery blood supply to a region of myocardium that results in cellular death and necrosis. • No elective dental care for atleast 6 mo postoperative.
  119. 119. Predisposing factors • Coronary artery disease (atherosclerosis) • Obesity • Sex • Stress • Type A behaviour pattern • Family history
  120. 120. Myocardial Infarction • Pain more intense and longer in duration than angina pectoris • Pain described as retrosternal, crushing, pressure, constriction, burning • Pain may occur in same distribution as angina pectoris • Not relieved by SL nitroglycerin or cessation of activity
  121. 121. MI Signs and Symptoms • Symptoms – Pain – Nausea/Indigestion – Weakness/Fatigue – Dizziness – Palpitations – Sense of impending doom – Lightheadedness • Signs – Restlessness – Acute distress – Vomiting – Cardiac arrhythmia – Pallor – Cyanosis – Dyspnea – Wheezing
  122. 122. Myocardial Infarction • Dialogue history – History of angina pectoris – Changes in angina pectoris – Previous MI • When, Treatment, Outcome, Current status – Medications – Risk factors
  123. 123. Management of Acute MI • Recognition • BLS – Airway – Breathing – Circulation – Activate EMS • Oxygen - 4-5 L by NC or face mask
  124. 124. Management of Acute MI • Monitor VS • Position to comfort • Pain relief – Morphine sulfate 2-5 mg IM/IV every 5-15 minutes – Mepiridine instead if respiratory rate <12/min • Prepare to perform CPR or provide ACLS (if properly trained)
  125. 125. DIFFERENTIAL DIAGNOSIS OF CHEST PAIN Condition Differentiating feature Musculoskeletal pain Pain is nonradiating, is made worse by breathing and movements Pericarditis Aggravation while breathing and swallowing, relief of pain when patient bends forward from waist, presence of fever before pain Esophagitis Precipitated by eating or lying down after meals and relieved by antacids Pulmonary embolism Coughing of blood tinged sputum Dissecting aortic aneurysm Pain spreads up and down the chest and back Gas Sharp and knifelike pain and increases in intensity upon breathing Acute indigestion Pain is similar to angina, careful evaluation required
  126. 126. HEART FAILURE • Heart failure is defined as inability of heart to supply sufficient oxygenated blood for metabolic needs of body. PREDISPOSING FACTORS – • increased workload of heart • damage to muscular walls of heart as in coronary artery disease and MI
  127. 127. DENTAL THERAPY CONSIDERATIONS • ASA I patients (no dyspnea or fatigue on normal exertion) – no special modification in dental therapy indicated. • ASA II patients (mild dyspnea or fatigue on exertion) – use of stress reduction protocol should be considered.
  128. 128. • ASA III patients (dyspnea or undue fatigue with normal activities) – medical consultation before starting any treatment. • ASA IV (dyspnea, orthopnea and fatigue all the times) - dental care should be withheld until the CV disorder is controlled. Management of dental emergencies should be handled with medications, and if physical intervention is required, patient should be hospitalized and placed under physician’s care while treatment.
  129. 129. MANAGEMENT • Terminate dental procedure • Position patient (upright position) • Activate EMS • Calm the patient • Basic life support as indicated • Administer oxygen • Measure vital signs • Alleviate symptoms of respiratory distress • Bloodless phlebotomy • Administer vasodilator • Alleviate apprehension • Subsequent dental care
  130. 130. CARDIAC CONDITIONS ASSOCIATED WITH ENDOCARDITIS High risk category Prosthetic cardiac valves Previous bacterial endocarditis Systemic – Pulmonary shunts Rheumatic and other acquired valvular dysfunction Hypertrophic cardiomyopathy Mitral valve prolapse with valvular regurgitation
  131. 131. Low risk or Minimal risk categories • Isolated secundum atrial-septal defect • Ventricular septal defect • PDA • Coronary artery bypass graft surgery • Mitral valve prolapse without regurgitation • Cardiac pacemakers and implanted defibrillators
  132. 132. Dental or oral surgical procedures Endocarditis prophylaxis recommended: • Procedures likely to induce gingival or mucosal bleeding. • Surgical operations involving respiratory mucosa (Maxillary sinus) • Incision and drainage of infected tissue • Intraligamentary injections
  133. 133. Prophylaxis not required • Procedures that do not involve bleeding • LA injections • New denture insertion
  134. 134. Recommended prophylactic regimen For patients able to take Amoxycillin Amoxycillin 3 gm orally 1 hour before procedure, 1.5 gm six hrs after initial dose For patients allergic to amoxycillin Erythromycin ethylsuccinate 800mg or Erythromycin stearate 1g orally 2 hrs before procedure and then one half the dose 6 hrs after initial dose
  135. 135. • For patients unable to take oral medications Ampicillin 2gm IV or IM 30 min before procedure, then 1gm IV or IM 6 hrs after initial dose Clindamycin 300mg IV 30 min before procedure and 150mg iv 6hrs after procedure
  136. 136. SEIZURES • paroxysmal disorder of cerebral function characterized by an attack involving changes in the state of consciousness, motor activity or sensory phenomenon.
  137. 137. TYPE OF SEIZURES Partial seizures (focal/ local) • Simple partial seizures/ jacksonian epilepsy (without loss of consciousness) • Complex partial seizures (with loss of consciousness) • Generalized seizures • Absence seizures • Atypical absence seizures • Myoclonic seizure • Clonic seizures • Tonic clonic seizures • Atonic seizure
  138. 138. Predisposing factors • Hypoxia, hypoglycaemia, hypocalcemia, stress, fatigue, missed meal, alcohol ingestion.
  139. 139. DENTAL THERAPY CONSIDERATIONS • Psychologic stress and fatigue tends to increase the probability of seizure developing. So psycho sedation should be considered in such patients. Inhalation sedation with nitrous oxide (upto 20%) and oxygen is highly recommended. • BZDs (diazepam, oxazepam, triazolam) are recommended for adult patients whereas chloral hydrate, promethazine and hydroxyzine are suggested for children.
  140. 140. MANAGEMENT OF PETIT MAL AND PARTIAL SEIZURES Diagnostic clues to presence of these seizures include: • Sudden onset of immobility and blank stare • Show blinking of eyes • Short duration • Rapid recovery
  141. 141. Terminate the dental procedure Position the patient comfortably Seizure stops seizure continues > 5 min Reassure patient summon medical assistance Allow patient to recover basic life support as indicated and discharge
  142. 142. GENERALIZED TONIC CLONIC SEIZURES Diagnostic clues: -Prodromal symptoms – marked anxiety or depression • Presence of aura prior to loss of consciousness • preictal phase- Loss of consciousness, epileptic cry, increase in HR and BP upto twice baseline, apnea
  143. 143. Ictal phase • tonic phase lasts from 10 to 20 seconds - dyspnea and cyanosis . • Clonic phase lasting for 2 to 5 minutes heavy, stertous breathing, frothing, blood from mouth, clenched teeth, tongue biting. Postictal phase • consciousness returns, urinary and fecal incontinence due to muscle flaccidity
  144. 144. MANAGEMENT Prodromal stage Terminate the dental procedure Ictal stage Position the patient (supine with legs elevated slightly Summon medical assistance Protect patient from injury Basic life support as indicated Administer oxygen Monitor vital signs Post ictal stage Basic life support as needed Reassure patient and allow to recover Discharge patient
  145. 145. MANAGEMENT OF STATUS EPILEPTICUS Prodromal stage Terminate the dental procedure Ictal stage Position the patient (supine with legs elevated slightly) Summon medical assistance Protect patient from injury Basic life support as indicated Administer oxygen Monitor vital signs Seizure continues > 5 min Basic life support perform venipuncture, until assistance arrives administer iv anticonvulsant administer 50% dextrose iv definitive management ( phenytoin (15mg/kg) Phenobarbital (10 to 15 mg/kg, Neuromuscular blockade with pancuronium)
  146. 146. THYROID GLAND DYSFUNCTION
  147. 147. Hypothyroidism Diagnostic clues : • Cold intolerance • Weakness • Fatigue • Dry, cold, yellow skin • Thick tongue
  148. 148. Management Terminate dental procedure Supine position A,B,C should be maintained Definitive care Summon emergency assistance Establish iv access, if possible (5% dextrose) Administer oxygen IV doses of thyroid hormone
  149. 149. Hyperthyroidsm Diagnostic clues: • Sweating • Heat intolerance • Tachycardia • Warm, thin, moist skin • Exophthalmos • Tremor
  150. 150. Management • Similar to that of hypothyroidism except that instead of thyroid hormone, antithyroid drugs are required in this case (eg propylthiouracil) and Glucocorticoids to prevent the occurance of acute adrenal insufficiency.
  151. 151. DENTAL THERAPY CONSIDERATIONS Hypothyroidism : - caution in using CNS depressant drugs like sedative – hypnotics, opoiod analgesics, antianxiety drugs, CNS depressants. • Hyperthyroidism :- stress in these patients can precipitate thyroid storm. Use of atropine, a vagolytic agent(inhibits vagus) should be avoided. Epinephrine should be used with caution (in minimal possible dose)
  152. 152. CEREBROVASCULAR ACCIDENT
  153. 153. • CVA is a focal neurologic disorder caused by destruction of brain substance as a result of intracerebral hemorrhage, thrombsis, embolism, or vascular insufficiency. • Also known as stroke, cerebral apoplexy, and “brain attack”.
  154. 154. CLINICAL MANIFESTATIONS OF CVAs INFARCTION • Gradual onset of signs and symptoms • TIA frequently preceding • Headache, usually mild • Neurologic signs and symptoms • Transient monocular blindness-TIA EMBOLISM • Abrupt onset of signs and symptoms • Mild headache preceding neurologic signs and symptoms HEMORRHAGE • Abrupt onset of signs and symptoms • Sudden, violent headache • Nausea and vomiting • Chills and sweating • Dizziness and vertigo • Neurologic signs and symptoms • Loss of consciousness
  155. 155. PATHOPHYSIOLOGY The following 2 important factors work together to produce a CVA: 1. The brain’s continual requirement for large amounts of O2 and energy substrate. 2. The inability of the brain to expand within its confining bony space, the cranium.
  156. 156. MANAGEMENT • Discontinuation of the dental procedure, activation of dental office emergency team • P (position)- Semi-Fowler position • A-B-C • D (definitive care) – Activation of emergency medical service (EMS) – Monitoring of vital signs – Management of signs and symptoms – Administration of O2
  157. 157. DRUG RELATED EMERGENCIES • Adverse drug reaction - defined as any noxious change which is suspected to be due to drug, occurs at doses normally used in men, requires treatment or decrease in dose or indicates caution in future use of same drug. • Side effects - these are unwanted but often unavoidable pharmacodynamic effects that occur at therapeutic doses.
  158. 158. • Secondary effects – indirect consequences of a primary action of a drug. • Toxic effects – these are the result of excessive pharmacological action of drug due to overdosage or prolonged use. • Allergy - Allergy may be defined as a hypersensitive state acquired through exposure to a particular allergen, re-exposure to which produces a heightened capacity to react. • Idiosyncrasy – it is a genetically determined abnormal reactivity to a chemical. • Anaphylaxis – it is a state of rapidly developing immune response to an antigen mediated by IgE antibodies.
  159. 159. Common drugs with their side effects drug allergy overdose Side effect LA Esters Amides Common esp with topical anesthetics, manifests as errythema and edema Rare Unlike with esters unless genetic deficiency is present. Most common ADR: CNS depression, drowsiness, tremor, tonic-clonic seizures Rare: sedation and drowsiness most common Rare : sedation most common Antibiotics Common Rare Rare: GI upset is most common Analgesics Nonnarcotic Narcotic Common; high allergic potential (asprin) – urticaria, bronchospasm, fatal anaphylaxis. Uncommon Common : salicylism Common – manifested as CNS depression, respiratory depression Common Most common ADR; nausea, vomiting, orthostatic hypotension Antianxiety agents Barbiturates BZDs N2O Uncommon Uncommon Rare Most common ADR; CNS depression, resp and CV depression, loss of consciousness Common ; CNS depression manifested as oversedation Common ; manifested as oversedation Common ; barbiturate hang over – lassitude and vertigo Drowsiness Most common; manifested as nausea/ vomiting
  160. 160. Allergy • Allergy may be defined as a hypersensitive state acquired through exposure to a particular allergen, re-exposure to which produces a heightened capacity to react. • Hypersensitivity state – Requires exposure to antigen – Body develops antibodies to antigen – Re-exposure to antigen elicits reaction
  161. 161. Allergy • Variable reactions – Dermatological (most common) – Respiratory • Nasal / Pulmonary – CNS – CV – Generalized anaphylaxis (rare)
  162. 162. Dermatological Reactions – Urticaria – Wheal and flare – Pruritis – Angioedema – Conjunctivitis – Rhinitis
  163. 163. Respiratory Reactions • Bronchospasm • Dyspnea, wheezing, flushing, cyanosis, diaphoresis, tachycardia, anxiety, accessory muscle use • Laryngeal edema • Stridor or crowing – May be indication of a developing generalized reaction
  164. 164. Common Allergens In Dentistry Antibiotics – Penicillins, Cephalosporins,Tetracyclines, Sulfonamides* Analgesics - Acetylsalicylic acid (aspirin), Nonsteroidal anti-inflammatory drugs Local Anesthetics – Esters - Procaine, Propoxycaine, Benzocaine, Tetracaine Preservatives - Parabens (methylparaben), Bisulfites, metasulfites, Other Allergens - Acrylic monomer (methyl methacrylate), Latex
  165. 165. Treatment • Dermatological reactions – Delayed (> 1 hour) • Diphenhydramine HCl 50 mg IM every 6 h, for 3-4 days
  166. 166. Management of Anaphylaxis / immediate onset systemic allergic reaction • Position patient in upright position • Assess ABC • Definitive management: 2 phases; – Acute phase management • Epinephrine (1:1000),0.3 mg IM or SC every 5 mins • Oxygen by nasal hood or face mask at rate of 5 to 6 L/min - Recovery phase management - Im histamine blocker - IV access and administration of additional histamine blockers and corticosteroids • -
  167. 167. Bronchospasm Treatment – Terminate therapy – Position patient to comfort – Oxygen 5-6 liters/minute via cannula or mask – Benadryl 50 mg every 6 h for 3- 4 days – Start an IV (if capable)
  168. 168. Laryngeal Edema Treatment – Epinephrine 0.3 mg IM or SC q 5 minutes – Maintain airway – Oxygen 5-6 liters/minute by face mask – Benadryl 50 mg IM or IV – Cricothyroidotomy (if necessary)
  169. 169. Local Anesthetics • Esters >>> Amides – Overall incidence very, very low – No esters available in dental cartridges • Antigenic components – Parabens - PABA, Methylparabens – Metabisulfite – Bisulfites
  170. 170. Penicillin • 2.5 million people allergic • Allergic reaction reported in 5- 10% of patients receiving penicillin • Fatal reaction in 1 per 100,000 • Most frequent cause of generalized anaphylaxis in dental practice
  171. 171. Overdose CAUSES • Rapid absorption • Intravascular injection • Delayed redistribution • Delayed biotransformation • Delayed elimination • Excessive dosage
  172. 172. Overdose • Predisposing factors – Patient factors – Drug factors
  173. 173. Patient Factors • Age • Weight • Sex • Other medications • Presence of disease • Genetics
  174. 174. Drug Factors • Vasoactivity • Concentration • Dose • Route of administration • Rate of injection • Vascularity at injection site • Vasoconstrictors
  175. 175. Local Anesthetic Overdose • Minimal - Moderate – Talkativeness – Apprehension – Excitability – Euphoria – Sweating – Disorientation – Increased BP, P, RR – Loss of reason • Moderate - High – Light headedness – Restlessness – Nervousness – Metallic taste • Visual, auditory disturbances – Seizures – CNS depression – CV collapse
  176. 176. Local Anesthetic Overdose • CNS precede CV symptoms • CNS symptoms – CNS depression or excitation – Seizures – Generalized CNS depression
  177. 177. Local Anesthetic Overdose Treatment – Oxygen – Monitor VS – BLS – IV line • Anticonvulsant (Valium) – Protect patient – Transfer to Em If necessary
  178. 178. EMERGENCY DRUGS
  179. 179. • Drugs are not necessary for the immediate management of most emergencies. • Primary management of all emergency situations is basic life support. • The emergency kit is a simple organized collection of drugs and equipments that has been found to be highly effective in managing those life threatening situations requiring the administration of these drugs.
  180. 180. EMERGENCY DRUGS 1. Adrenaline 11. Pancuronium bromide 2. Atropine 12. Styptochrome 3. Dopamine 13. Ethamsylate 4. Metoclopramide 14. Ketorolac 5. Phenaramine maleate 15. Aminophylline 6. Hydrocortisone 16. Succinyl choline 7. Dexamethasone 17. Dextrose 8. Diazepam 18. Sodium bicarbonate 9. Fortwin-pentazocin 19. Calcium gluconate 10. Furosemide 20. Chlorpheniramine maleate
  181. 181. CLASSIFICATION Emergency drugs Injectables Non Injectables Oxygen Vasodilators Respiratory stimulants Anti Hypoglycaemic agents Bronchodilators Primary Secondary Drug for advanced cardiac life support 1) Adrenaline 1 Analgesic 1) Lidocaine 2) Antihistamine 2)Vasopressor 2) Atropine 3) Anti convulsant 3)Corticosteroid 3) Sodium bicarbonate 4) Narcotic antagonist 4)Antihypoglycaemic
  182. 182. Modules for these drugs are: • Module one – basic emergency kit (critical drugs and equipment) • Module two – noncritical drugs and equipment • Module three – advanced critical life support • Module four – antidotal drugs
  183. 183. MODULE ONE : CRITICAL / ESSENTIAL EMERGENCY DRUGS AND EQUIPEMENT • Injectable drugs 2 drugs – both used for same emergency – acute allergy. These are: • Epinephrine • Antihistamine • Noninjectable drugs • Oxygen • Vasodilator • Emergency equipement • Oxygen delivery system • Suction and suction tips • Tourniquets • Syringes
  184. 184. PRIMARY INJECTABLE DRUGS FOR ACUTE ALLERGIC REACTIONS • Drug of choice: epinephrine • Drug class: natural catecholamine • Alternative drug : none available • Used in management of respiratory and cardiovascular manifestations of allergic reactions, anaphylaxis, cardiac arrest.
  185. 185. • Desirable properties:- rapid onset of action, bronchial smooth muscle dilator, antihistaminic properties • Undesirable actions:- dysarrythmias and short duration of action, should be used with caution in pregnant women as it decreases placental blood flow and may induce premature labour.
  186. 186. • Availability : 1:1000 concentration or 1:10,000 concentration ( for iv administration) • Suggested for emergency kit – one preloaded syringe(1 ml of 1:1000)for acute allergic reactions and three to four ampules of 1:1000 epinephrine (for anaphylaxis), one preloaded syringe containing 1;10000 adr for cardiac arrest.
  187. 187. TRADE NAME : Adrenor, Asmotone DOSAGE : 0.2-0.5 mg s.c , ADVERSE EFFECTS - Marked increase in BP - photosensitivity, skin rashes - palpitation, arrythmias - anginal pain, ventricular failure
  188. 188. • 2. Drug of choice – Chlorpheniramine • Drug class – Antihistamine • Alternative drug – Diphenhydramine • Used for delayed allergic reactions • Properties : potent local anaesthetic, causes sedation
  189. 189. • Side effects – CNS depression, decreased BP, thickening of bronchial secretions(CI in asthamatics) • Availability – Chlorpheniramine 10 mg/ml (1 ml ampule), 2ml ampule, also in 1 ml preloaded syringe. • Diphenhydramine – 10mg/ml (10 and 30 ml multidose vials) and 1 ml preloaded syringe. • Suggested for emergency kit – 3 or 4 ampules of any of the two.
  190. 190. CRITICAL NONINJECTABLE DRUGS • 1. Oxygen: recommended size is E cylinder, which is quite portable and supplies oxygen for 30 minutes. • Indications – any emergency situation in which respiratory distress is evident.
  191. 191. 2. Vasodilator • Drug of choice – Nitroglycerine • Alternative drug – Amyl nitrite • Indicated in management of chest pain, acute MI, acute hypertensive episodes. • Placed sublingually or sprayed onto lingual soft tissues, acts in 1 to 2 minutes.
  192. 192. • Shelf life of TNG is 6 weeks once exposed to air, so drug should be replaced every 6 weeks in emergency kit. Translingual spray has longer shelf life than tablets. • Amyl nitrite, another vasodilator is available for use as an inhalant, produce vasodilation in approx 10 sec. • 0.1, 0.3, 0.6mg sublingual tablets, translingual spray (nitrolingual 0.4mg/dose); amyl nitrite vaporoles 0.3ml.
  193. 193. • Side effects and CI – transient pulsating headache, facial flushing and hypotension (more with amyl nitrite)
  194. 194. MODULE 2: NONCRITICAL EMERGENCY DRUGS AND EQUIPMENTS Secondary injectable drugs Seven drugs: • Anticonvulsants • Analgesics • Vasopressors • Antihypoglycemics • Corticosteroids • Antihypertensives • Anticholinergics
  195. 195. Noninjectable drugs • Respiratory stimulant • Antihypoglycemic • Bronchodilator • Secondary Emergency equipments • Device for cricothyrotomy • Artificial airways • Laryngoscope and endotracheal tubes
  196. 196. SECONDARY INJECTABLE : ANTICONVULSANT • Drug of choice : Midazolam • Drug class : Benzodiazepine • Alternative drug: Diazepam
  197. 197. • Indications – status epilepticus, local anaesthetic seizures, hyperventilation (for sedation), thyroid storm(for sedation) • Side effects – respiratory depression • Availability –Midazolam, Dormicum and Hyponovel: 5mg/ml in 1, 2, 5 and 10 ml vials and 2 ml preloaded syringe
  198. 198. Secondary injectable : analgesic • Drug of choice – morphine sulphate • Drug class – Narcotic agonist • Alternative drug – Mepiridine (Demerol) • Indications – intense prolonged pain; acute MI, CHF • Side effects – CNS and respiratory depressants, CI in victims of head injury. Respiratory depressant action may be reversed by use of naloxone.
  199. 199. • Availability – morphine sulphate 8, 10 and 15 mg/ml (in 2ml ampules and 20ml vials • Mepiridine 50 and 100mg/ml (in 1 ml ampule and 20 and 30ml vials • Recently mixture of 35 to 50 % N2O and O2 is used in place of narcotics in management of pain associated with MI. It provides the victim with 2 ½ to 3 times the ambient level of oxygen.
  200. 200. Secondary injectable: Vasopressor • Drug of choice : Methoxamine (Vasoxyl) • Drug Class: Vasopressor • Alternative Drug : Phenylephrine (Neosynephrine)
  201. 201. • Uses – Syncopal reactions • Drug overdose reactions • Postseizures state • Acute adrenal insufficiency • Availability –Methoxamine 10 mg/ ml (2 to 3, 1ml ampules) or phenylephrine 10mg/ml (2 to 3, 1 ml ampules) • Vasopressors are used only as a last resort only after other measures to raise BP like trendlenberg position has failed.
  202. 202. Secondary injectable :antihypoglycemic • Drug of choice – 50% dextrose • Drug class – antihypoglycemic • Alternative drug : Glucagon • Side effects – 50% dextrose which is used IV, produce tissue necrosis if extravascular infiltration occur. If given in an already hyperglycaemic patient, blood sugar level will not be elevated significantly. • Availability – 50% dextrose (50 ml vial), glucagon 1mg dry powder with 1 ml diluents.
  203. 203. Secondary injectable: Corticosteroid • Drug of choice: Hydrocortisone sodium succinate • Drug class – adrenal glucocorticosteroid • Alternative drug: Dexamethasone • Mainly these are used in allergic rxns, to prevent recurrent episodes of anaphylaxis. Also important in management of acute adrenal insufficiency. • Available as Cortef 50mg/ml(2ml vial), decadron 4mg/ml
  204. 204. Secondary injectable: antihypertensive • Drug of choice : Labetalol (Normodyne) • Drug class: beta adrenergic blocker • Alternative drug : Propanolol
  205. 205. • Side effects – postural hypotension, CI in patients with asthma, overt heart failure, heart block, cardiogenic shock and severe bradycardia • Availability: Labetalol HCl injection: 5mg/ml in 20 and 40 ml multidose vials and in 4 ml and 8 ml prefilled syringes.
  206. 206. Secondary injectable: Parasympathetic blocking agent • Drug of choice: Atropine • Drug class; Anticholinergic • Alternative drug: none • Used for management of symptomatic bradycardia (< 60 beats per minute), acts by activating SA node. • Essential drug in ACLS (Advanced cardiac life support) for management of bradydysrhythmias.
  207. 207. • Side effects : dose > 2 mg may produce clinical signs of overdosage including hot, dry skin, headache, blurred near vision, dryness of mouth and throat, disorientation and hallucinations. CI in patients with glaucoma or prostatic hypertrophy. • Availability: 0.5mg/ml in 1 ml vial and 1 mg in 10 ml syringe.
  208. 208. Secondary non injectable drugs • Respiratory stimulant : • Drug of choice: aromatic ammonia • Uses – respiratory depression, vasodepressor syncope • Availability: silver grey vaporole (0.3ml aromatic ammonia) • Side effects, contraindications, and precautions: COPD or asthma
  209. 209. Antihypoglycemics: • Drug of choice: sugar • Side effects and CI : liquid carbohydrate preparations should not be used in patients with diminished gag reflex. Parentral administration is recommended in these situations. • Availability: Glucola, Gluco stat, Insta glucose, decorative icing
  210. 210. Bronchodilator : • Drug of choice: Albuterol • Drug class: adrenergic agonist • Alternative drug: metaproterenol • Side effects, contraindications, cardiovascular side effects - including tachycardia and ventricular dysrhythmias
  211. 211. Antihypertensive • Drug of choice: Nifedipine • Drug class: Calcium channel blocker • Alternative drug : Nitroglycerin
  212. 212. • Used primarily for management of angina, especially vasospastic or Prinzmetal’s variant angina. • Side effects – excessive hypotension especially in patients receiving beta blockers and are undergoing anaesthesia with high doses of fentanyl. • Availability – 10 mg or 20 mg capsules
  213. 213. Module three : Advanced cardiac Life Support – Essential drugs Drug Indication Antiarrhythmics Lidocaine Ventricular tachycardia, pulseless, ventricular tachycardia, or ventricular fibrillation Procainamide Ventricular tachycardia, pulseless ventricular tachycardia or ventricular fibrillation Bretylium Ventricular tachycardia, pulseless ventricular tachycardia or ventricular fibrillation Verapamil, diltiazem Atrial flutter or atrial fibrillation, paroxysmal supraventricular tachycardia Adenosine Paroxysmal supraventricular tachycardia Atropine Bradycardia, asystole, first-degree and Mobitz type I atrioventricular block, Mobitz type II and third-degree block Magnesium Torsades de pointes, ventricular fibrillation β blockers (e.g., propranolol) Atrial flutter or atrial fibrillation, refractory ventricular tachycardia or ventricular fibrillation
  214. 214. Inotropes Epinephrine Ventricular fibrillation, asystole, pulseless, electrical activity, bradycardia Norepinephrine Refractory hypotension Dopamine Bradycardia, hypotension Dobutamine Congestive heart failure Isoproterenol Refractory bradycardia Digitalis Atrial flutter, fibrillation Amrinone Refractory congestive heart failure
  215. 215. Vasodilators/Antihypertensives Nitroprusside Hypertension, acute heart failure Nitroglycerin Hypertension, acute heart failure, anginal pain
  216. 216. Others Sodium bicarbonate Hyperkalemia, metabolic acidosis with bicarbonate loss, hypoxic lactic acidosis Furosemide Acute pulmonary edema Morphine Acute pulmonary edema, pain and anxiety Thrombolytic agents (e.g., anistreplase) Acute myocardial thrombosis
  217. 217. Module 4: antidotal drugs • 1. Narcotic antagonist • Drug of choice – Naloxone • Drug class – Thebaine derivative • Alternative drug – Nalbuphene • Indications – narcotic induced depression • Side effects – respiratory depression if employed for longer duration >30 min • Acute withdrawal syndrome
  218. 218. • Availability – 0.4mg/ml in 1 ml ampule and 10 ml vials. • Pediatric – 0.02 mg/ml
  219. 219. BZD antagonist • Drug of choice – Flumazenil • Side effects – rebound anxiety • Availability – 0.1mg/ml in 1 omL multidose vial
  220. 220. Antiemergence delirium • Drug of choice – Physostigmine • Drug class – reverse anticholinesterase • Side effects – increased salivation, involuntary urination and defecation • Atropine is antidote for Physostigmine • Availability – 1mg/ml in 2 ml ampules
  221. 221. Antidote for LA • Drug of choice – Procaine • Class – ester LA • Side effect – allergy to esters. • Availability – 1% solution in 2 ml and 6 ml ampules.
  222. 222. References • Medical emergencies in Dental Practice – Malamed • Emergencies in Dental Practice- McCarthy • Management of Medically Compromised Patients – DCNA Oct, 2008 • Oral medicine – Tyldesley’s • Oral and Maxillofacial surgery- Daniel Laskin
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