medical emergencies in dental clinic

1. MEDICAL EMERGENCIES IN A
DENTAL OFFICE
PRESENTED BY: Dr SHERMIL SAYD

2. • Its a rare occurrence and managing it can be frightening
experience
• The doctor and the staff should be adequately prepared.
Otherwise the result would be a catastrophe
• Simple preventive measures can prevent medical emergencies
• A thorough medical history should be taken
• If any doubt exists regarding the medical status of the patient
the patients physician should be contacted, and a letter or
note concerning the patients medical status should be taken
and the condition should be stabilized before any elective
procedure is to be carried out.

3. • During any procedure, the doctor and the surgical team
should observe the patient carefully if any medical
emergencies arise, it should be managed by the doctor and
his staff who is well trained in giving CPR and life saving
medications.
• Drugs and equipments should be checked periodically to
ensure that the drugs are not outdated and that the
equipments are functioning properly
• Emergency numbers should always be within reach.

4. The emergency medicines to be kept in a dental clinic includes
• Oxygen
• Aromatic ammonia
• Nitroglycerine tablets
• Diphenhydramine
• Atropine, 0.5mg/ml vial
• Epinephrine
• Vasopressors
– Phenyephrine 10m/ml
– Methoxamine. 10mg/ml or 20mg/ml
– Norepinephrine, 0.2%, 4 ml ampule
– Ephedrine, 50mg/ml
– Mephenteramine15mg/ml
– mataraminol

5. • Sodium bicarbonate
• Calcium chloride
• Lidocaine
• Isoproterenol, 1mg ampule
• Morphine, 8mg/ml
• Meperidine
• Steroids
– Methylprednisolone sodium succinate
– Hydrocortisone sodium succinate
• Procaine
• Naloxone
• Diazepam
• Aminophylline

6. • Sugar
– Sugar cubes or small packages
– Dextrose, 50% or 50ml vial
• Glucagon 1mg dry powder with 1ml dilutent
• Succinylcholine chloride
• Sterile water for injection

7. Emergency equipment
• Equipment to administer oxygen
• Oropharyngeal airways
• Endotracheal tubes and connectors
• Laryngoscope and blades
• Suction catheter
• Tonsillar suction tip and hose
• Cricothyroid cannula
• Scalpel blades and handle
• Needles- 22,25 gauges, butterfly(19, 21) & angiocath

8. • Syringes-1ml, 5ml, 10ml, 50ml
• IV fluid(5% D/W, 5% D/S, LR) and administration set
• Tourniquet
• Stethoscope
• Sphygmomanometer
• Hemostats
• Padded tongue blades
• Tape
• K-Y jelly
• Alcohol sponges

9. Latest emergency drugs4

11. Syncope
• Transient loss of consciousness secondary to cessation or decreased
cerebral blood flow-wintrobe1974
• Most common untoward reaction in dental clinics-ADA1975
• More prevalent in young people and highest incidence in men
under 35years- hannington kiff 1969
• Common predisposing factor includes pain, anxiety, sight of blood,
physical and mental exhaustion, hot environment, debility, fasting
and minor surgical procedures-chue 1975
• These factors trigger a vasodepressor action, with dilation of blood
vessels in the skeletal muscles and the splanchnic region
• A fall in the peripheral resistance with decreased venous treturn to
the heart results, leading to a fall in arterial pressure

12. • Vagal reflexes are activated, causing bradycardia, a reduction
in the cardiac output, and a further reduction in the blood
pressure, all leading to decreased cerebral perfusion
• Always preceded by prodrome lasting from secs to mins
during which the patient has feeling of warmth, weakness,
possible epigastric discomfort or nausea and general sense of
being feeling badly
• Then patient develop sweating, pallor, coldness of the
extremities and dizziness, with slight increase in pulse and BP
• If not treated promptly it will lead to marked ashen gray
pallor, shallow respirations, slow and weak pulse, low BP and
dilated pupils

13. Treatment:
• Place the patient in supine position with legs elevated to
increase venous return to the heart
• Tight constricting clothing should be loosened
• A patent airway should be maintained
– Remove foreign bodies from the mouth
– Suctioning of excess salivary secretions
– Bringing the lower jaw forward
– Insert oropharygeal airway
• Administer oxygen if patient is cyanotic-chue 1975
• Routine use of oxygen in syncope-campbell et al 1976

14. • Check vital signs
• BP and pulse for several mins, adjunctive therapy should be
started
• Still low along with bradycardia, atropine (0.4mg IV)
• If hypotension without bradycardia, then vasopressor such as
phenylephrine(2-5mg IV) or methoxamine HCl(5mg IV/15mg
IM) should be used
• After recovery, patient should be brought out of the supine
position very slowly

15. Prevention-
• Always try to keep the patient in a supine or somewhat
reclining position during treatment
• Relieve fear and anxiety
• Good pain control

16. Hyperventilation
• An ↑ in alveolar ventilation caused by abnormally rapid and
deep breathing
• The form commonly seen in the dental office is the
hyperventilation syndrome usually caused by fear and anxiety
• Not common occurrence
• Precipitated by anxiety, fear, excitement, nervousness,
emotional stress and psychoneurotic reactions
• Most common in women who are somewhat anxious and
nervous
• It causes hypocapnia- rotsztain and co workers, 1970
• It cause reduction in the cerebral blood flow and resp.
alkalosis

17. • Respiratory alkalosis favors a reduction in the calcium levels
leading to muscular spasms and symptoms suggestive of
tetany- seamonds et al, 1972
• Recognition
– Dizziness and difficulty in breathing
– Palpitations and tightness or mild pain in the chest
– Epigastric discomfort
– Numbness, tingling or paresthesia of the fingers, toes and lips
– Muscular twitching, carpopedal spasms and tetany .
– Headache, faintness, fatigue and mental confusion
– Loss of consciousness

18. Treatment:
• Maintain patent airway
• Mental rapport in calming the patient
• If the patient overbreathe, he should be allowed to breath
into a paper bag or ambu mask at a rate of 10 times per min
• After symptoms abate the patient should be allowed to
breathe room air at a rate of 12-14 times per min

19. Prevention-
• Follow stress reduction protocol
• Administration of sedation

20. Allergic reactions
• Results from an immunologic response by a patient who has
become sensitized to the drug through a prior exposure
• Can be either cellular(delayed) or humoral(immediate)
• Cellular reaction is mediated by cellular reaction mediated by
lymphocytes derived from the thymus gland which react
directly with an antigen
• Humoral type mediated through serum antibodies that are
produced by lymphocytes derived from the bone marrow
• Humoral allergic responses may vary from a mild skin reaction
to anaphylaxis
• More common in adults than in children

21. Recognition:
• Skin reactions
• Drug fever
• Organ cytotoxicity
• Serum sickness
• Anaphylaxis
• Most common is the skin eruptions which can be
– Urticarial
– Bullous
– Erythematous
– Maculopapular
– Nodular
– Edematous
– petechial

22. • Can be accompanied by pruritis and edema
• Respiratory problems
– Allergic rhinitis
– Edema
– Bronchospasm
– Wheezing
– Dyspnea
– Cyanosis
– Asphyxia
• Circulatory problems
– Pallor and mild hypotension
– Vascular collapse
– Irreversible shock

23. Treatment:
• Treated as soon as possible
• Cutaneous symptoms
– Antihistamines orally
– Severe cases- IM or IV route preferred using diphenhydramine HCl
50mg or other suitable anti histamines followed by oral tablets
– If it progresses and extensive edema is present then epinephrine
1:1000 should be injected subcutaneously or IM. And may be repeated
in 10-15 mins if necessary
• respiratory symptoms-
– Bronchospasm and wheezing
– 0.3-0.5mg 1:1000 epinephrine should be given SC/IM and repeated in
10-15 mins

24. – Patent airway should be maintained
– Oxygen administration
– Respiration should be supported when necessary
– Antihistaminic drug should be given after that followed by
corticosteroids-hydrocortisone 100mg or methylprednisolone 40mg or
dexamethasone 8mg IM/IV can be given
– Steroids require more than one hour to act, so it should always be
given after the other drugs
• Circulatory symptoms
– Moderate reaction treated same as the respiratory symptoms
– If the reaction is truly an anaphylactic shock, then
• Place the patient in a supine position
• Maintain ABC
• Administer epinephrine 1:1000 0.5mg IM
• Monitor vital signs
• Titrate epinephrine 0.2 to 0.3 mg IV slowly if IV route is available
• Administer IV fluid rapidly
• Administer antihistamines IV/IM
• Administer steroid IM/IV
• Recognize and treat any concomitant problem, i.e. vomiting, convulsion,
cardiac arrhythmias

25. Prevention:
• Take accurate history
• Patients should be observed for a valid period of time after a
drug has been administered

26. Airway obstruction by foreign body
• Caused by swelling of the neck owing to infection or trauma,
tumors growing in the airway, unconsciousness causing the tongue
to fall back and block the airway or foreign bodies at any level along
the air passages
• When a foreign body disappears from the oral cavity and there are
signs of bronchial irritation, it must be presumed to have passed
into the respiratory passage until proved otherwise-McCarthy 1972
• Symptoms may be mild or patients may cough, gag choke, or
wheeze
• If only mild symptoms are present then a radiograph of the chest
should be taken to confirm the location of the body, then should be
referred for its removal bronchoscopy or thoracotomy if
bronchoscopy is unsuccessful

27. • With complete obstruction the patient may gasp for breath
with great effort, show suprasternal and intercostal retraction
and be unable to speak
• The chest may rise and fall, but this should not be considered
as air exchange until it can be felt with the back of the hand-
thompson 1975

28. Treatment:
• Try leaning the patient over the chair and pound on his back
• Small children may be held upside down by their legs and
sharp blows rendered to their backs
• If unsuccessful the patient should be laid supine on the floor
and with head to the side and the mouth pen, the middle and
index finger should be placed deep into the pharynx and
swept laterally in an effort to dislodge the foreign body
• If laryngoscope and Magill forceps are available, then it can
also be used for the removal
• If the obstruction is incomplete, then mouth to mouth or
ambu bag can be used to move enough air round to be life
saving

29. • Another procedure to be considered before attempting
surgical intervention is Heimlich procedure- Heimlich 1974
• This maneuver increases the pressure in the trachea and
larynx and dislodges the obstruction

30. • If all else fails then surgical intervention is necessary
• Cricothyroidotomy or coniotomy is the procedure of choice
• Cricothyroid space is located easily by observation and no
major nerves or vessels pass through that region
• If airway maintenance is required for more than 48 hrs, then a
tracheotomy should be considered

31. Prevention:
• Utilize care when dealing with the instruments inside the oral
cavity
• A gauze screen protecting the pharynx should be placed
whenever the patient is undergoing procedures under GA or
sedation

32. Asthma-Bronchospasm
• Generalized contraction of the smooth muscles of the bronchi and
bronchioles
• Seen commonly in patients with asthma
• With an asthmatic attack there is bronchospasm, mucosal edema
and intraluminal secretions all of which contribute to airflow
obstruction
• Present as very mild with few symptoms or as status asthmaticus, a
life threatening episode initially unresponsive to therapy with
hydration and bronchodilators wheezing is a prominent sign
• Patient may be diphoretic, anxious and shows labored breathing
with use of accessory muscles and intercostal retraction

33. • Subjectively, patient shows
– Shortness of breath
– Wheezing
– Chest tightness
– Chest congestion
• This is followed by symptoms of fatigue, panic fear and
irritability(kinsman et al, 1973)
• Leads to hypoxemia which can result in cyanosis and
confusion

34. Treatment
• Consist primarily of bronchodilators, supplemented with
oxygen and hydration
• Patient should be in an sitting position
• Oxygen administration 20-30%is useful but is seldom used
• First try the medication the patient is having and using
• If that is unavailable, then epinephrine 0.3-0.5mg SC should
be administered and may be repeated in 15mins.
• If this fails, then aminophylline should be used
• A loading dose of 5-6mg/kg in 5% D/W can be given
intravenously over 15-20mins
• Following loading dose, 1mg/kg/hr can be started. Stopped at
the sign of irritation

35. • If asthma still persists, then the patient should be carried into
an emergency room
Prevention;
• Proper medical history should be taken and anything which is
allergic to the patient should be removed
• Elective surgery should be delayed if the patient complains of
any respiratory diseases
• Mild sedation should be used
• Narcotics should be avoided
• Aspirin should be avoided as it can worsen the condition in
several patients

36. Hypertensive emergency
• When a resting adult has an arterial pressure above 150/90 mm
Hg, hypertension may be considered to be present
• They have possibility of ↑ed bleeding problems related with
therapy with antihypertensive medication and increased sensitivity
to sedatives and epinephrine
• Acute HT episode should be considered when an extremely high
elevation of diastolic BP, 120mmHg or greater is seen along with
– Headaches
– Dizziness
– Nausea
– Vomiting
– Signs of visual impairment
– Other neurologic changes

37. • Retinal changes
– Hemorrhages
– Exudates
– Papilledema
• If not treated promptly it may lead to other complications
such as angina pectoris or stroke

38. Treatment:
• Try to reduce the blood pressure to a range of 100-110mmHg
• Patient should be allowed to rest in a semi resting position
• Oxygen administration
• Small amount of diazepam slowly titrated IV route, to reduce
the blood pressure
• Small dose of chlorpromazine can also be used to lower the
blood pressure
• if oxygen and small amount of diazepam, is not able to reduce
the blood pressure, then the patient should be carried out to
the OT

39. Prevention:
• An accurate medical history should be taken
• A preoperative BP should be take to assess the BP and to
measure it as a baseline
• Should always consider the possibility of orthostatic
hypotension when under antihypertensive medication
• A maximum of 0.2mg epinephrine per appointment is
permissible( NY heart association, 1955)
• Avoid intravascular injection
• Sedation should be encouraged as this helps the patients to
relax and avoid any HT crisis

40. Hypotensive emergency
• It is the ↓ in BP and should be diagnosed from shock
• The pulse may be weak
• Bradycardia
• A systolic pressure less than 80mmHg is considered as
hypotensive
• If shock is also associated then the patient will also show
agitation, restlessness, confusion, nausea, stupor and
coma(staples 1973)

41. Treatment:
• Initially supportive therapy
• Patient should be placed in trendelenburg’s position and
oxygen administered
• Vital signs should be monitored upon closely
• IV line should be administered for possible fluids and drugs
• If pulse <60, atropine 0.4-0.6mg IV
• In patients using antihypertensive medications,
norepinephrine or phenylephrine should be used
• Phenylephrine 2-5mg SC/IM preferred or 0.2mg IV infusion
can also be used

42. • If MI or cerebrovascular accident is suspected, then least
potent vasopressor, mephenteramine can be used IV/IM. A
dosage of 15mg for systolic BP in between 60-80. if <60, 30mg
can be used
Prevention:
• Take proper medical history

43. Ischemic heart disease
• Results from an inadequate perfusion of a portion of the
myocardium
• Etiology include atherosclerosis of the coronary arteries
• Resultant ischemia may lead to arrhythmias, conduction
defects or cardiac failure
• Majority of the patients present with angina pectoris, MI or
sudden death
• Angina pectoris is a paroxysmal discomfort often described as
heaviness, tightness, choking or squeezing(Herman 1971)
• The pain is characteristically retrosternal but may radiate to
the arms and shoulders, particularly on the left side

44. • The pain is relieved by rest or nitroglycerine
• Pain of MI is similar to angina pectoris, but is more severe and
prolonged, not alleviated by rest or nitroglycerine and other
symptoms like weakness, pallor, nausea, sweating and
restlessness are more often seen

45. Treatment:
• The procedure should be stopped and the patient should be
put in a semisitting position and oxygen administered
• A tablet of nitroglycerine, preferably the patients own
medication is placed sublingually. If the patient has no
nitroglycerine, a 0.03mg nitroglycerine tablet should be
placed under the tongue.
• If effective, relief should be seen in 45 seconds to 2 mins. If
pain persists, sublingual nitroglycerine can be placed twice at
5min interval.
• If the pain is severe an ampule of amyl nitrate broken under
the patients nose can be tried

46. • If effective it should provide relief within 30 secs.
• Since these drugs are vasodilators, headache, flushing
dizziness and even syncope can be seen
• If all fails, then the patient should be suspected to have MI
and the patient should be send to the emergency room
• If heart failure develops, corrective measures should be
instituted
• If pain is severe, meperidine 25mg can be given IM/IV titer
• If hypotension is present, mephenteramine 15-30mg IM can
be given
• CPR should be instituted if respiratory depression exists

47. Prevention:
• Take proper medical history
• Risk factors
– Hypertension
– Cigarette smoking
– hypercholesterolemia
– sex
– Age
– Obesity
– DM
– Positive family history
– Aggressive, deadline conscious personality

48. • If the patient is giving history of stable angina, then short
appointments and sedation should be considered to minimize
stress
• In case of unstable angina, elective surgery should be carried
out with the physicians consultation
• With a recent history of angina, the treatment should be
postponed for atleast 6 months

49. Congestive heart failure
• It is the inability of the heart to pump sufficient blood to the
body tissues to meet ordinary body demands(parmley 1977)
• problems in the dental office includes, signs and symptoms of
heart failure in patients with underlying heart disease or a
change from chronic to acute heart failure during surgical
treatment
• With left heart failure
– Dyspnea
– Orthopnea
– Paroxysmal nocturnal dyspnea
– Chronic cough
– bronchospasm

50. • With right heart failure
– ↑ed jugular venous distension
– positive hepatojugular reflex
– Hepatomegaly
– Peripheral edema
• General heart failure
– Fatigue
– Weight loss
– Tachycardia
– A third heart sound
– Cardiac enlargement

51. • The symptoms of general heart failure is accentuated by
pulmonary edema, with the occurrence of bronchospasm and
cyanosis
• There is often frothy pink sputum production and chest is
filled with rales which can be heard on auscultation

52. Treatment:
• Based on the underlying cause, reducing the cardiac load and
controlling excessive fluid retention
• Digitalis is useful in these cases due to its inotropic effect
• When acute pulmonary edema is present, patient should be
placed in sitting or semisitting position to reduce the venous
return to the heart
• Oxygen 100% administered possibly under positive pressure
• Morphine can be given IM/IV to decrease vascular resistance
and in turn decrease the venous return
• Dosage depends upon the severity and route of
administration of the drug

53. • Tourniquets or blood pressure cuffs can be placed on the
upper and lower limbs, being applied to constrict the veins to
restrict the blood supply and does not interfere with the
arterial supply
• Rapidly acting furosamides and digitalis are also utilized
• If bronchospasm present, then aminophylline can be used

54. Prevention:
• Proper medical history
• If a patient has an episode of acute ischemic episode in the
office, patient should be observed carefully for development
of heart failure
• Patient should be placed in sitting or semisitting position

55. Cardiopulmonary arrest
• It is the sudden cessation of the circulation and ventilation
• Causes include
– GA
– LA
– Sedation
– Asphyxia
– MI
– Allergic reactions to medications
• Lack of ventilation can be identified by the lack of thoracic or
abdominal movements, the absence of air movements from
the mouth or the nose.

56. • Absence of circulation is identified by the absence of femoral
or carotid pulse, confirmed by the manifestations of
inadequate cerebral perfusion, i.e. dilated pupils,
unresponsiveness, comatose state, and by inadequate
peripheral perfusion by the ashen gray color.

57. Treatment:
• CPR
• BLS consists of the ABC of the CPR
– A- maintaining the airway
– B-breathing
– C-circulation
• Started ASAP, because irreversible heart damage can cause within
4-6 mins
• Most important immediate action is the opening 0of the airway
• If spontaneous breathing doesn’t resume, then artificial ventilation
should be started using anesthetic machine r ambu bag or mouth to
mouth respiration or mouth to nose ventilation

58. • Oropharygeal airway and endotracheal intubation- only
should be used when the patient is unconscious
• Once the patency of the airway is established, then
ventilation should be continued at the rate of once every 5
secs in adults and once every 3 secs in infants and small
children
• Supplemental oxygen should be used as soon as possible
• if circulation is absent, then artificial circulation by external
cardiac massage should be initiated
• With only one rescuer, a ratio of 15:2 should be maintained,
i.e. 15 chest compressions for 2 quick lung inflations

59. • Pupils that constrict in response to light indicate adequate
blood flow to the brain
• After 2 mins of CPR, sodium bicarbonate, 1mEq/kg should be
given IV as a bolus or as a continuous infusion over a ten min
period to combat metabolic acidosis
• Initial dose should be repeated after 10 mins, thereafter half
the dose at every ten mins
• It should be used along with epinephrine which increases
myocardial contractility, elevates perfusion pressure, helps
restore electrical activity and enhances defibrillation in
ventricular fibrillation
• Dosage-0.5mg IV every 5 mins

60. • Atropine-sinus bradycardia with a pulse less than 60beats/min
• Dosage-0.5mg IV repeated at 5 min interval until the pulse exceeds
60bpm
• Defibrillation should be carried pout in case of ventricular
fibrillation
• Complications of CPR
– Fracture of the ribs and sternum or separation and fracture of the
costochondral junctions
– Fat and bone marrow emboli
– Hemothorax
– Pneumothorax
– Hemopericardium
– Lacerations of the liver, spleen and the stomach

62. Prevention:
• Good history
• Recognizing high risk patients
• Adequate monitoring during the procedure

63. Diabetic emergencies
• Two complications
– Insulin shock(hypoglycemia)
– Ketoacidosis (hyperglycemia)
• Both conditions are more likely to occur in patients who have
onset juvenile diabetes
• Hypoglycemia is the more common occurrence in dental
office
• Occurs when there is inadequate carbohydrate intake in
relation to the insulin or oral hypoglycemic medication
• Ketoacidosis usually develops over a period of several days
• Symptoms are usually caused by excessive sympathetic
activity

64. • They usually occurs when the blood glucose falls below
40mg%
• Patient may show pallor, sweating and tremor and may have
apprehension palpitations weakness and hunger
• with inadequate cerebral glucose, irritability, mental
confusion, depression, headache and other neurologic
symptoms such as speech and visual disturbances will occur
• If no treatment is instituted, then convulsion, coma, or death
may ensue
• They usually have a slightly elevated BP and pulse

65. • In diabetic ketoacidosis, patient gives a history of thirst,
polyuria, and polydipsia and may have nausea, vomiting,
abdominal pain, confusion, and ultimately coma
• Rapid breathing
• Odor of acetone may appear in the breath
• Patient appears ill and dehydrated due to polyuria
• Rapid pulse, ↓ed BP and skin turgor, dry mouth and
enophthalmus

66. Treatment:
• Hypoglycemia-
– Administer 10-20gm of glucose or its equivalent orally
– unconscious- giving glucose 20-50ml of 50% glucose should be
administered IV route
– If failed to give in IV route, then 1mg of glucagon can be given IM, SC.
Its peak action occurs within 10-15 mins
• Ketoacidosis
– Best if carried out in a hospital because it requires giving administering
insulin, monitoring fluids and electrolytes, vital signs, blood gases and
other parameters
– Patient should be placed in a supine position and should be
transported into the hospital

67. Adrenal insufficiency
• Occurs with patients who are taking steroids or has been
taking steroids
• Causes the suppression of the anterior pituitary
• Duration of the treatment is more important than the amount
of drug taken
• When exogenous steroids are given for less than ten days, the
pituitary adrenal axis recovers within a mater of hours.
• When it is given for more than a year, then it will take as much
as 9 months to recover
• ACTH suppression is less likely to occur after two months of
the cessation of the treatment

68. • Consultation with the physician is necessary before
commencing the treatment in steroid treatment taking or
taken patients
• It is characterized by
– Anxiousness
– Severe nausea and Vomiting
– Abdominal pain
– Cool and clammy skin
– Lethargy and hypotension
– Shock

69. Treatment:
• Administration of steroids to ↑ the circulating hormone level
• If the patient is responsive, then 100 to 200mg of a soluble
hydrocortisone preparation added to 1000ml of 5% D/S
allowed to run over 4 hrs is often advocated
• 100mg cortisone acetate is also given to prolong the action
• Profound shock- 100mg hydrocortisone IV
– If no response then the dosage can be ↑ed to 400-500mg
• Vasopressors can also be used to combat hypotension

70. Prevention:
• Good medical history
• Physicians opinion if the patient has taken medication for
– Arthritis
– Asthma
– Regional enteritis
– Ulcerative colitis
– Some types of hepatitis
– Pemphigus
– Severe dermatoses
– For prevention of graft rejection in kidney transplant patients
– Conjugation with other medications for the treatment of malignancies

71. • Recommendation for steroid taking patients
– Mild stress- double the daily dose
– Moderate stress- oral hydrocortisone 100mg or prednisolone 20mg
daily
– Severe stress- hydrocortisone 200mg or prednisolone 40mg

72. Epileptic convulsion
• Chances of seizure occurring during the treatment
• Status epilepticus, two or more seizures occurring without
intervening consciousness is the most possibility having a
mortality rate of about 10-20%
• Convulsions may also occur due to infection, fever, neurologic
problems, metabolic imbalances and toxic reactions to drugs
including LA
• A grand mal epileptic seizure is usually characterized by
generalized seizure usually lasting less than 5 mins, preceded
by aura that may consist of sensor, motor or psychic
sensations

73. • There is loss of consciousness, urinary or fecal incontinence
and one usually sees injury from falling or tongue and cheek
biting
• Respirations might become jerky
• The postictal stage is usually characterized by drowsiness,
headaches and confusion

74. Treatment:
• Airway maintenance, patient protection and patient protection and
termination of convulsions
• Patent airway should be maintained and any oral appliances or
dental prosthesis should be removed immediately tight restricting
clothing should be removed
• Oxygen administration to protect against hypoxia
• If vomiting occurs, then the head should be tilted to the side and
the oral cavity should be suctioned off of any vomit or saliva
• By judiciously restraining the patient, injury during the seizure can
be prevented
• Tongue biting should be prevented using tongue blades or towels

75. • If convulsion doesn’t stop for several minutes, drug should be
administered
• Diazepam 5-10mgIV(5mg/min)
• In children, 0.25 to 0.50mg/kg
• Initial dose might be repeated after 5 to 10 mins
• Maximum dose 30mg/hr
• Can be given IM if IV route is difficult
• Succinyl choline IV/IM can also be used

76. Prevention:
• Adequate history
• Procedures delayed if the patient is not under good control
• If a patient has seizure in the office he should be taken home
with assistance because of postictal depression

77. Cerebrovascular accident
• Unlikely event in a dental office
• Result from thrombosis, embolism or hemorrhage all of which
result in focal brain damage
• Mainly afflicts elderly population with atherosclerosis being
the most common reason
• Other reasons include
– Vascular malformations
– Inflammatory diseases of the arteries
– Hematologic disorders
– Hypertension
– Hypotension
– Drugs such as oral contraceptives and anticoagulants

78. • Hallmark of CVA is the sudden change in neurologic function
with the specific symptoms depending on the area and extent
of brain damage
• Weakness, hemiplegia, hemianesthesia and speech and visual
problems may occur. Severe headache is frequent if its due to
hemorrhage

79. Treatment:
• Mainly supportive
• Patient should be kept comfortable
• Patent airway should be maintained and oxygen administered
If respiratory difficulty develops
• The head should be kept elevated to reduce the risk of
hemorrhage
• Patient should be immediately transported to the hospital for
further treatment

80. Prevention:
• Look for the susceptible patients which includes
– Elderly patients
– Hypertensive patients
– Patients with evidence of arteriosclerosis, which includes angina
pectoris, MI, or peripheral vascular disease

81. conclusion
• Taking an adequate medical history can prevent many mishaps in
the dental office.
• If in doubt about the status of the patient, the treatment should
always be postponed until a physicians concern is obtained.
• A clinician should always be alert ad should be able to identify the
condition and instate proper treatment at the right time. At the first
sign of the patient being stable, he should be shifted to higher
centre for proper medical treatment without delay
• All the emergency medicines should be at reach and always the
medication should be kept ready and staff should know where all
the medications are

82. ALWAYS BE PREPARED

83. REFERENCES
1. ORAL AND MAXILLOFACIAL SURGERY. DANIEL M LASKIN
2. CLINICAL MEDICINE-MURRAY LANGMORE
3. MEDICAL EMERGENCIES IN DENTAL OFFICE-STANLEY F
MALAMED
4. Haas A Management of Medical Emergencies in the
DentalOffice: Conditions in Each Country, the Extent of
Treatment by the Dentist: Anesth Prog 53:20–24 2006
5. Fast TB, Martin MD, Ellis TM. Emergency preparedness:a
survey of dental practitioners. J Am Dent Assoc.
1986;112:499–501
6. New Zealand Code of Practice Medical Emergencies in
Dental Practice
7. The ADA Practical Guide to Patients with Medical Conditions

84. 8. Basic management of medical emergencies Recognizing a
patient’s distress-JADA 2010;141(5 suppl):20S-24S
9. INTERNET RESOURCES