ภาวะฉุกเฉินทางอายุรกรรมแยกตามกลุ่มอาการ
I. Unconscious, Altered conscious
1. Vasodepressor syncope
2. Orthostatic hypotension
3. Hypoglycemia
Diabetes mellitus
4. Hyperglycemia
5. Acute adrenal insufficiency
6. Thyroid crisis
7. Cerebrovascular accident (CVA)
II. Respiratory difficulty
1. Asthma
2. Hyperventilation syndrome
3. Heart failure and acute pulmonary edema
III. Chest pain
1. Angina pectoris
2. Acute myocardial infarction
IV. Local anesthetic reactions
1. Epinephrine overdose
2. Local anesthetic overdose
3. Allergy – anaphylactic shock
4. Hyperventilation syndrome*
5. Vasodepressor syncope*
V. Seizures
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ภาวะหมดสติ
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ภาวะเปลี่ยนแปลงการมีสติรบั รู้
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ภาวะการหายใจลาบาก
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ภาวะการเจ็บหน้ าอก
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ปฏิกิริยาต่อการฉี ดยาชาเฉพาะที่
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ปฏิกิริยาต่อการฉี ดยาชาเฉพาะที่
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อาการชัก
-8-
Management of the unconscious patient
Step 1 Recognition of unconsciousness “Shake and shout”
Painful stimuli
Step 2 Call for help
Step 3 Position patient
Supine position
Step 4 Open airway
Head tilt – chin lift
Step 5 Assess airway patency and breathing
Place ear 1 inch from patient’s nose/mouth
Hear and feel air from lungs
Look at patient’s chest/abdomen
See movement of chest/abdomen
Step 6 Jaw thrust maneuver (if needed)
Dislocation of mandible
Tilting head backward
Opening mouth with fingers
Step 7 Assess airway patency and breathing
Place ear 1 inch from patient’s mouth/nose
Hear and feel air from lungs
Look at patient’s chest/abdomen
See movement of chest/abdomen
Step 8 Artificial ventilation
Exhaled air ventilation (16%)
Mouth – to – mouth ventilation
Mouth – to – nose ventilation
Atmospheric air (21%)
Bag – valve – mask units
Artificial airways
Oropharyngeal
Nasopharyngeal
S tubes
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Enriched oxygen (up to 100%)
E cylinder with face mask
Demand/positive pressure valve
Inhalation sedation unit
Step 9 Assess circulation
Carotid artery (adult/child)
Brachial artery (infant)
Step 10 Definitive management of unconsciousness
Management of vasodepressor syncope
Step 1 Place patient in supine position with feet slightly elevated
Step 2 Establish patent airway
Head tilt – chin lift method
Check breathing
Jaw thrust maneuver if necessary
Recheck breathing if necessary
Artificial ventilation if necessary
Check circulation
Step 3 Monitor vital signs
Blood pressure
Heart rate
Respiratory rate
Support patient
Ammonia vaporole crushed under nose of patient
Cold towel to forehead
Blankets if cold or shivering
Step 4 Maintain your composure
Step 5 Follow – up treatment
Determine factors causing unconsciousness
Prevent recurrence of vasodepressor syncope
Arrange for patient to be taken home by friend or relative
No further dental treatment for 24 hours
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Management of orthotatic hypotension
Step 1 Place patient in supine position with feet elevated slightly (at a 10-degree angle)
(Note : in late stages of pregnency the lateral position is preferred)
Step 2 Maintain airway
Head tilt – chin lift
Check breathing
Jaw thrust maneuver, if necessary
Oxygen, if necessary
Monitor vital signs
Step 3 Make position changes slowly
Step 4 Discharge patient
Management of acute adrenal insufficiency
Conscious patient
Step 1 Terminte dental therapy
2 Monitor vital signs
3 Position patient
4 Emergency kit (oxygen)
5 Administer glucocorticosteroid
6 Summon medical assistance
Unconscious patient
Step 1 Recognize unconsciousness
2 Position patient
3 Basic life support
4 Emergency kit (oxygen)
5 Summon medical assistance
6 Evaluate medical history
7 Administer glucocorticosteroid
7a Additional drugs (vasopressor)
8 Transfer to hospital
Management of respiratory difficulty
Step 1 Recognition of respiratory difficulty
Sounds (wheezing, cough)
Abnormal rate and/or depth of respiration
Step 2 Terminationof dental procedure
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Step 3 Position patient, implement basic life support
Unconscious – supine position
Conscious – upright position usually preferred by patient
Step 4 Monitor vital signs
Blood pressure, heart rate (pulse) respiratory rate
Step 5 Symptomatic management of patient
Step 6 Definitive management of respiratory difficulty
Management of acute airway obstruction
Step 1 Recognition unconsciousness
Step 2 Call for help
Step 3 Position victim (supine)
Step 4 Head tilt
Step 5 Assess airway and breathing
Step 6 Attempt to ventilate
Step 7 Reposition head (head tilt) and attempt to ventilate
Step 8 Jaw thrust maneuver
Step 9 Attempt to ventilate
Step 10 Activate EMS system
Step 11 Deliver 6 to 10 abdominal thrusts
Step 12 Check mouth for foreign body
Step 13 Attempt to ventilate
Step 14 Repeat step 11 to 13 until successful
Step 15 Cricothyrotomy
Management of the hyperventilation syndrome
Goals : Reduce anxiety and restore chemical balance of blood
1. Anxiety reduction
Step 1 Terminate dental procedure
Step 2 Position patient in any comfortable position
Step 3 Remove foreign materials from mouth
Step 4 Calm patient (latrosedation)
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2. Correct respiratory alkalosis
Step 5 Breath CO2 –enriched air through brown paper bag, full face mask, or hands cupped over face
Step 6 Drug management
Diazepam or midazolam
IV (titrate)
IM (10 mg. Diazepam or 5 mg. Midazolam deeply injected; massage)
Oral (10 to 15 mg.) diazepam
Step 7 Follow – up
Determine cause of anxiety; treat anxiety through psychosedation
Note : Oxygen is not indicated for use in the hyperventilation syndrome
Management of asthma
Step 1 Terminate dental therapy
Step 2 Position patient
Comportable position
Usually sitting with arms thrown forward
Step 3 Administer bronchodilator by means of aerosol spray
Epinephrine, isopreterenol, or metaproterenol (read instructions carefully before use)
Step 4 Administer oxygen
Step 5 Parenteral medication
If episode continues, epinephrine 1 : 1,000 IM 0.3 ml. (adult); IM 0.125 ml. (infant);
IM 0.25 ml. (child)
Step 6 Intravenous medications (optional)
If episode continues, aminophylline 250 mg. By means of a very slow IV; hydrocortisone
sodium succinate, 100 to 200 mg. IV.
Step 6a Summon medical assistance if step 6 is needed or if episode is refractory to management
Step 7 Regarding further dental therapy: terminate therapy for day
Permit patient to recover fully before discharge
Management of heart failure and acute pulmonary edema
Step 1 Place patient in upright position
Step 2 Administer oxygen (nasal cannula preferred)
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Step 3 Record vital signs
Blood pressure
Heart rate and thythm
Respiratory rate
Step 4 Alleviate symptoms of respiratory difficulty
Place patient in upright position
Bloodliss phlebotomy, rotating toruniquets
Step 5 Alleviate apprehension
Meperidine 50 mg. IM, or Morphine 10 mg. IM. (for adults)
Step 6 Summon medical assistance
Management of altered consciousness
Step 1 Recognition of altered consciousness
Skin
Cold and wet
Hot and dry
Hot with excessive sweating
Cold and dry
Breath
“Acetone” breath
Headache, dizziness, confusion
Step 2 Terminate dental procedure
Step 3 Position patient
Conscious – upright position usually preferred by patient
Unconscious – supine position
If CVA is considered and elevated blood pressure is present, head and thorax should be elevated
slightly
Step 4 Basic life support
Step 5 Monitor vital signs
Blood pressure, heart rate (pulse), respiratory rate, and temperature
Step 6 Management of signs and symptoms
Step 7 Definitive management
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Hypoglycemia
Conscious patient
Step 1 Recognition of hypoglycemia
Step 2 Assess airway, breathing and circulation and implement as necessary
Step 3 Administer oral carbohydrates
Step 4 Permit patient to recover
Unresponsive conscious patient
Step 1 Recognize hypoglycemia
Step 2 Assess ABCs.
Step 3 Administer oral carbohydrate
Step 4 Administer parenteral carbohydrate
Step 5 Summon medical assistance
Unconscious patient
Step 1 Basic life support
Step 2 Summon medical assistance
Step 3 Definitive management
Management of thyroid gland dyfunction
Hypofunction or hyperfunction under therapy (euthyroid)
Step 1 Manage normally
Clinical evidence of hypofunction or hyperfunction
Step 1 Prior medical consultation
Step 2 Judicious use of durgs
CNS – depresants: sedative, narcotic, antianxiety drugs (hypofunction)
Atropine and epinephrine (hyperfunction)
Unconscious patient
Step 1 Basic life support
Step 2 Summon medical assistance if no response
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Management of the patient with hyperglycemia or hypoglycemia
Hyperglycemia /diabetic acidosis
Hypoglycemia/insulin shock
Predisposing factors
Onset of symptoms
Insulin level
Food intake
Gardual (days)
Insufficient
Normal to excessive
Sudden (minutes to hours)
Excessive
May be inadequate
Clinical signs and symptoms
Skin appearance
Mouth
Thirst
Hunger
Vomiting
Abdominal pain
Respirations
Breath odor
Blood pressure
Heart rate
Tremor
Convulsions
Dry and flushed
Dry
Intense
Absent
Common
Frequent
Exaggerated (Kusmaul)
Acetone
Low
Weak and rapid
Absent
None
Mois and pale
Drooling
Absent
Occasional
Rare
Absent
Normal to shallow
Normal
Normal
Full and bounding
Frequent
In late stages
Gardual
Overall – insulin
Dental office – basic life support
medical assistance
Rapid
Carbohydrate : oral, IV dextrose
(50%), IM glucogon (1 mg.), IM
epinephrine (0.5 mg.); (with
unconscious patient, provide basic life
support, medical assistance and
carbohydrate)
Management
Response to treatment
Management
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Management of CVA
Transient ischemic attack
Step 1 Terminate dental therapy
Step 2 Initiate basic life support
Step 3 Manage signs and symptoms
Step 4 Monitor vital signs
Step 5 Follow – up management
Consult with physsician regarding future management
Discharge patient with adult companion
CVA in the conscious patient
Step 1 Terminate dental therapy
Step 2 Initiate basic life support
Step 3 Manage signs and symptoms
Step 4 Monitor vital signs every 5 minutes
Step 5 Summon medical assistance after 10 to 15 minutes
CVA in the unconscious patient
Step 1 Position patient (supine)
Step 2 Basic life support
Airway
Breathing
Step 3 Record vital signs
CPR if indicated
Reposition patient
Supine with head elevated slightly in presence of elevated blood pressure or signs of
hemorrhagic CVA; supine if CPR is indicated
Step 4 Summon medical assistanc eimmediately
Note :
1. Any drug with potential for CNS depression should be avoided in the acute CVA patient.
2. Oxygen should be employed in TIA and the conscious CVA patient only in the presence of
respiratory difficulty. It may be freely used if unconscioussness is present.
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Management of tonic-clonic seizures
Convulsive (ictal) phase
Step 1 Position patient (supine)
Step 2 Prevent injury to patient
Soft object under head
Soft object between teeth, if possible
Loosen tight clothing
Step 3 Initiate basic life support
Step 4 Monitor vital signs
Postical phase
Step 5 Initiate basic life support
Step 6 Permit patient to recover, contact physician
Step 7 Discharge patient in company of reponsible adult companion
Grand mal status
Step 1 Position patient (supine)
Step 2 Prevent injury to patient
Step 3 Initiate basic life support
Step 4 Monitor vital signs
Step 5 Administer anticonvulsant drug
Diazepam 2 mg./min. slowly and intravenously (for adult)
Pentobarbital 25 mg./min slowly and intravenously
Step 6 Summon medical assistance
Management of Local – anesthetic overdose
Mild overdose reaction (rapid onset)
No formal therapy
Step 1 Reassure patient
Step 2 Administer oxygen
Step 3 Initiate basic life support
Step 4 Monitor vital signs
Step 5 Administer anticonvulant (optional)
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Step 6 Recovery
Mild overdose reaction (slow onset)
Step 1 Reassure patient
Step 2 Administer oxygen and instruct patient to hyperventilate
Step 3 Initiate basic life support
Step 4 Monitor vital signs
Step 5 Venipuncture if available (diazepam 2 mg./min until reaction stops)
Step 6 Summon medical assistance
Step 7 Medical consultation
Step 8 Recovery
Severe overdose reaction (rapid onset)
Step 1 Position patient (supine)
Step 2 Manage seizures
Prevent injury
Loosen tight graments
Step 3 Basic life support
Ensure patent airway
Administer oxygen
Monitor vital signs
Step 4 Anticonvulsant after 4 to 5 minutes (diazepam 2 mg./min IV if possible)
Manage post seizure depression
Airway maintenance
Oxygen, artificial ventilation
Step 5 Additional management
Summon medical assistance
Monitor vital signs
CPR if indicated
Methoxamine, 20 mg. IM for low blood pressure
Step 6 Permit patient to recover before discharge to hospital
Severe overdose reaction (slow onset)
Step 1 Terminate dental therapy
Step 2 Basic life support and oxygen
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Step 3 Anticonvulsant, if symptom progress
Step 4 Summon medical assistance
Step 5 Manage post seizure depression
Basic life support
Vasopressor, if necessary
Step 6 Permit patient to recover before discharge to hospital
Management of epinephrine overdose
Step 1
Step 2
Step 3
Step 4
Step 5
Step 6
Terminate dental procedure
Position patient – not supine
Reassure patient
Initiate basic life support
Monitor vital signs, administer oxygen
Allow patient to recover
Management of allergic reactions
Skin reaction (delayed)
Step 1 Initiate basci life support, as needed
Step 2 Antihistamine IM (diphenhydramine 50 mg. Chlorpheniramine 10 mg. and Oral antihistamine)
Step 3 Medical consultation
Skin reactions (immediate)
Step 1 Initiate basic life support, as needed
Step 2 Epinephrine 0.125 – 0.3 ml. of 1 : 1,000 IM. SC
Step 3 Antihistamine IM
Step 4 Consult with physician
Step 5 Observe patient
Step 6 Oral antihistamine
Respiratory reaction – bronchial constriction
Step 1 Terminate dental therapy
Step 2 Position patient (semierect)
Step 3 Initiate basic life support as needed
Step 4 Administer oxygen
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Step 5 Epinephrine via aerosol inhaler or 0.125 –0.3 ml. of 1 : 1,000 IM. SC
Step 6 Observe patient
Step 7 Antihistamine IM or IV
Step 8 Medical consultation
Step 9 Oral antihistamine
Respiratory reaction – laryngeal edema (partial obstruction)
Step 1 Position patient (supine)
Step 2 Epinephrine 0.125 – 0.3 ml. of 1 : 1,000 IM. SC.
Step 3 Airway maintenance (head tilt)
Step 4 Summon medical assistance
Step 5 Additional drug therapy anthistamine and corticosteroid IM or IV
Laryngeal edema (total obstruction)
Step 1 Position patient (supine)
Step 2 Epinephrine 0.125 – 0.3 ml. of 1 : 1,000 IM. SC
Step 3 Oxygen
Step 4 Summon medical assistance
Step 5 Antihistamine and corticosteroid IM or IV
Step 6 Cricothyrotomy (if needed)
Step 7 Transfer to hospital
Generalized anaphylaxis (if allergy symptoms appear)
Step 1 Position patient (supine)
Step 2 Initate basic life support
Step 3 Epinephrine 0.125 – 0.3 ml. of 1 : 1,000 IM. SC
Step 4 Summon medical assistance
Step 5 Monitor vital signs every 5 minutes
Step 6 Additional drug therapy antihistamine and corticosteroid IM or IV
Step 7 Transfer to hospital
Generalized anaphylaxis (no signs of allergy present)
Step 1 Position patient (supine)
Step 2 Initiate basic life support
Step 3 Monitor vital signs every 5 minutes
Step 4 Summon medical assistance
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Dental therapy consideration in angina pectoris
Frequency of angina
0-1 per month
Patient’s abilities
ASA
physical
status
Considerations
Patient can walk two level city
blocks or climb one flight of
stairs
Patient can walk two level city
blocks or clime one flight of
stairs
II
Usual ASA II considerations and
supplemental oxygen
II
Pain develops before patient
walks two level city blocks or
climbs one flight of stairs
III
Daily apisodes or recent (within Patient unable to walk two level
past 2-3 weeks) changes in
city blocks or climb one flight
character of episode :
of stairs
Increased frequenecy, duration
or severity
Radiation to new site
Precipitated by less acitivity
Decreased pain relief with usual
nitroglycerin dose
IV
Usual ASA II considerations to
include possible
premedication with
nitroglycerin 5 minutes before
therapy and supplemental
oxygen
Usual ASA III consideration to
include possible
premedication with
nitroglycerin 5 minutes before
therapy and supplemental
oxygen
Usual ASA IV considerations
2-4 per month
2-3 per week
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Management of angina
Step 1 Terminate dental therapy
Step 2 Position patient (upright position most comfortable)
Step 3 Administer vasodilator
Nitroglycerin preferred
Step 4 Amyl nitrite, if needed
Nifedipine, if needed
Step 5 Other medications
Oxygen, if needed
Narcotics contraindicated in angina
Step 6 Modify further dental therapy to prevent recurrence
Management of acute myocardial infarction
Step 1 Diagnosis
Administer nitroglycerin
Step 2 Initiate basic life support and implement as needed
Step 3 Summon medical assistance
Step 4 Administer oxygen and monitor vital signs
Step 5 Relieve pain
SC or IV morphine or meperidine or a nitrous oxide – oxygen mixture by means of a nasal hood
Step 6 Manage complications
Dysrhythmias : Do not administer antidysrhythmic agents unless electrocardioscope is present
Congestive heart failure see
Cardiac arrest see
Step 7 Transport patient to hospital, doctor should accompany patient to hospital
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ขนาดและวิธีการบริหารยาที่ใช้ในภาวะฉุกเฉิน
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ขนาดและวิธีการบริหารยาที่ใช้ในภาวะฉุกเฉิน (ต่อ)
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ขนาดและวิธีการบริหารยาที่ใช้ในภาวะฉุกเฉิน (ต่อ)
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