Emergency in Dentistry: Part II

1. Emergency in Dentistry: Part II Hypersensitivity Chest discomfort Respiratory difficulty Altered consciousness Metabolic problems

2. Hypersensitivity Reactions • Type I: • - immediate, acute and life- • threatening • - mediated primarily by IgE • - previous exposure history

3. Hypersensitivity Reactions • Skin signs: • - erythema, urticaria, pruritis, angioedema • Respiratory tract signs: • - wheezing, mild dyspnea • - stridor, moderate to severe dyspnea

4. Hypersensitivity Reactions

5. Epinephrine Nasal cannula

7. Differential Diagnosis of Acute Chest Pain: Common Causes • Cardiovascular: angina pectoris, MI • Gastrointestinal: dyspepsia (heart burn), hiatal hernia, reflux esophigitis, gastric ulcer • Musculoskeletal: intercostal muscle spasm • Psychologic: hyperventilation

8. Differential Diagnosis of Acute Chest Pain: Uncommon Causes • Cardiovascular: pericarditis, dissecting aneurysm • Respiratory: pulmonary embolism, pleuritis, tracheobronchitis, mediastinitis, pneumothorax • Gastrointestinal: esophageal rupture, achalasia • Musculoskeletal: chostochondritis • Psychologic: psychogenic chest pain

9. Chest Discomfort:--- AMI or angina pectoris • Pain pattern - Characteristics: squeezing, bursting, pressing, burning or choking - Location: substernum - Refer pain: L’t shoulder, arm, neck or mandible - Associated with exertion, anxiety - Relieved by vasodilator (ex. NTG) or rest - May accompanied by dyspnea, nausea& vomiting sensation, palpitation

10. Angina pectoris • Terminate all procedures • Semi-reclined position • Sublingual NTG • O2 • Check vital signs Discomfort relieved Still discomfort after 3min 6. Assume angina pectoris was present 7. Slowly taper O2 over 5min 8. Modify dental treatment Give 2nd NTG Still discomfort after 3min Give 3rd NTG Still discomfort after 3min NTG 0.6mg/tab

11. 10. Assume myocardial infarction in progress 11. On IV line 12. Prepare transport to ER If highly suspected AMI MONA:Morphine, Oxygen, NTG, Aspirin

12. Respiratory Difficulty: • Asthma • Hyperventilation • Chronic obstructive pulmonary disease (COPD) • Foreign body aspiration • Gastric contents aspiration

13. Manifestations of An Acute Asthmatic Episode: • Mild to moderate - wheezing - dyspnea - tachycardia - coughing - anxiety

14. Manifestations of An Acute Asthmatic Episode: • Severe - intense dyspnea with flaring of nostrils & use of accessory muscle - cyanosis of mucous membrane & nailbeds - minimal breathing sound on auscultation - flushing - extreme anxiety - mental confusion - perspiration

15. Asthma • Terminate all procedures • Fully sitting position • Bronchodilators (Atrovent/Berotec) • O2 • Check vital signs S & S relieved Signs & symptoms continue 6. Monitor of recovery state 7. Consult physician 6. Give Epi 0.3ml of 1: 1,000 IM or SQ 7. Build up IV line 8. Monitor vital signs S & S not relieved 9. Prepare to ER 10. Add steroid therapy

16. Manifestations of Hyperventilation Syndrome: • Neurologic - dizziness - tingling or numbness of fingers, toes or lips - syncope • Respiratory - increased rate & depth of breaths - SOB - chest pain - xerostomia

17. Manifestations of Hyperventilation Syndrome: • Cardiac - palpitations - tachycardia • Musculoskeletal - myalgia - muscle spasm - tremor - tetany • Psychologic - extreme anxiety

18. Management of Hyperventilation Syndrome: • Terminate all procedures • On fully upright position • Verbally calm patient • Breath CO2-enriched air • Add Valium 10mg IM or IV; Dormicum 5mg IM or IV • Monitor vital signs

19. Anxiety Increased cathecholamine release Decreased peripheral vascular resistance Pooling of blood periphery Decreased ABP Reflex vagally mediated bradycardia, nausea, weakness & hypotension Compensatory mechanisms cause increased HR, feeling of warmth, pallor, perspiration, rapid breathing Decompensation occur Reduced cerebral blood flow Lightheadness, syncope (if prolong) Seizure activity • Vasovagal syncope

20. Vasovagal syncope • Prodrome: • Terminate all procedures • Supine position with leg elevation • Attempt to calm patient • Cool towel to forehead • Monitor vital signs • Syncopal episode: • Terminate all procedures • Supine position with leg elevation • Check breathing Atropine 1mg/amp Used in severe bradycardia Not exceed 2mg If absent: 4. Start BLS 5. Prepare to ER 6. Consider other cause If present: 4. Ammonia under nose 5. Monitor vital signs 6. Plan anxiety control at next visit

21. Manifestations of Seizure Attack: • Isolated, brief seizure - tonic-clonic movement of trunk & extremities - loss of consciousness - vomiting - airway obstruction - loss of urinary & anal sphincter control • Repeated or sustained seizure (status epileptics)

22. After seizure attack Patient unconscious Patient conscious • Place on side and suction airway • Monitor vital signs • Initiate BLS • Administer O2 • Prepare to ER • Suction airway • Monitor vital signs • Administer O2 • OBS for at least 1hr and consult physician If sustained • Diazepam 5mg/min IV • Dormicum 3mg/min IV or IM • Dialantin 10~15mg/kg IV

23. Manifestation of acute hypoglycemia

24. Hypoglycemia Terminate all procedures • Mild S & S: • Administer oral glucose source • Monitor vital signs • Consult physician • Intake before next visit • Moderate S & S: • Administer oral glucose source • Monitor vital signs • IV D50, 50ml or glucagon 1mg • Consult physician • Severe S & S: • IV D50, 50ml or glucagon 1mg • Prepare to ER • Monitor vital signs • Give O2

25. Manifestations of acute adrenal insufficiency: • Weakness • Feeling of extreme fatigue • Confusion • Hypotension • Nausea • Abdominal pain • Myalgias • Partial or total loss of consciousness

26. Decardron 5mg Hydrocortisone 100mg Management of acute adrenal insufficiency: • Terminate all procedures • Supine position with leg elevation • Administer hydrocortisone 100~200mg or Decardron 5~10mg • Administer O2 • Monitor vital signs • Set up IV line • Start BLS if indicated

27. Thanks for Your Attention !!!

28. Manifestation and management of local anesthesia toxicity

29. Suggested maximum dosage of local anesthetics