ADRENAL INSUFFICIENCY
• The adrenal cortex produces mineralocorticoids and
glucocorticoids that are important in maintaining fluid
volume.
• Cortisol, the principal glucocorticoid, maintains
extracellular fluid.
• Aldosterone, the principal mineralocorticoid, regulates salt
and water balance.
• Insufficient production of these hormones can result from
primary (Addison’s disease) or secondary adrenal disease.
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Primary Adrenocortical Insufficiency
Caused by a progressive destruction of the adrenal cortex.
Idiopathic nature
Autoimmune
Hemorrhage
Sepsis
Infectious diseases (such as tuberculosis, human
immunodeficiency virus, cytomegalovirus and fungal infection)
Malignancy
Adrenalectomy
Drugs
Clinical evidence of the deficiency generally arises only after
90 percent of the adrenal cortices have been destroyed.
Affected patients have high levels of adrenocorticotropic
hormone or ACTH in blood, and a very low to undetectable
level of aldosterone and cortisol in blood.
Secondary Adrenocortical Insufficiency
• Results from hypothalamic or pituitary disease and from
the administration of exogenous corticosteroids. Although
classified together, these two entities have different
physiological effects.
• In the absence of hypothalamic or pituitary function, the
adrenal cortex undergoes irreversible atrophy.
• Long-term administration of corticosteroids blunts adrenal
cortical function, with variable and reversible effects.
• Cases of hypothalamic-pituitary disease are less common
than those induced by use of corticosteroids.
ADRENAL CRISIS
• The most acute adverse outcome of AI is adrenal crisis.
This event can occur when a patient with AI, most
commonly in the form of Addison’s disease, is challenged
by stress (Eg; illness, infection or surgery) and in response
is unable to synthesize adequate cortisol & aldosterone.
• This life-threatening emergency usually evolves slowly
during a few hours and then is manifested by severe
exacerbation of the condition including profuse sweating,
hypotension, weak pulse, cyanosis, nausea, vomiting,
weakness, headache, dehydration, fever, sunken eyes,
dyspnea, myalgia, arthralgia, hyponatremia & eosinophilia.
• If not treated rapidly, patient can develop hypothermia,
severe hypotension, hypoglycemia, confusion and
circulatory collapse.
ACUTE ASTHMA
• Asthma is described as a chronic inflammatory disorder
involving many cell types, manifesting with episodes of
chest tightness, coughing, labored breathing and wheezing,
all of which are related to bronchiole inflammation.
Symptoms can last for a few moments or as long as days.
• The airway obstruction in asthma is initiated by
inflammation and muscle spasm but is mostly reversible.
• It generally is believed that both genetic and environmental
factors, as well as allergens, are important in the initiation
and continuation of the airway inflammation.
MANAGEMENT IN DENTAL CARE
CHEST PAIN (ANGINA PECTORIS )
• Angina pectoris commonly known as angina is severe
chest pain due to ischemia (a lack of blood supply, hence a
lack of oxygen supply) of the heart muscle, generally due
to obstruction or spasm of the coronary arteries.
• Coronary artery disease, the main cause of angina, is due to
atherosclerosis of the cardiac arteries.
Classification
• Stable angina
• Unstable angina
• Stable angina / effort angina is that of chest discomfort and
associated symptoms precipitated by some activity
(running, walking, etc.) with minimal or non-existent
symptoms at rest.
• Unstable angina occurs at any time and should be
considered and managed as a form of acute coronary
syndrome.
Signs and Symptoms
• Most patients with angina complain of chest discomfort
rather than actual pain described as a pressure, heaviness,
tightness, squeezing, burning, or choking sensation.
• Apart from chest discomfort, anginal pains may also be
experienced in the epigastrium (upper central abdomen),
back, neck area, jaw, or shoulders. This is explained by the
concept of referred pain, and is due to the spinal level that
receives visceral sensation from the heart simultaneously
receiving cutaneous sensation from parts of the skin.
• Typical locations for referred pain are arms often inner left
arm, shoulders, neck and into the jaw.
• Angina is typically precipitated by exertion or emotional
stress. It is exacerbated by having a full stomach and by
cold temperatures.
• The pain usually lasts for about 3 to 5 minutes but the
symptoms actually starts 15 to 20 minutes before the pain
and is relieved by rest or specific anti-angina medication.
MANAGEMENT OF CHEST PAIN WITH
ANGINA PECTORIS
Recognize problem
(chest pain, patient states he/she is having an anginal attack)
Discontinue dental treatment
Activate office emergency team
P— Position patient comfortably
A- B- C- Assess airway, breathing, and circulation
D— Provide definitive management
HISTORY OF ANGINA PRESENT
Administer vasodilator and O, (up to 3 doses)
NO HISTORY OF ANGINA
Activate EMS, STAT
IF PAIN
IF PAIN DOES
administer O2 and
RESOLVES
NOT RESOLVE
consider nitroglycerin
Consider future dental
Activate EMS
Administer Aspirin
Monitor and record vital signs
Monitor and record
ACUTE MYOCARDIAL INFARCTION
• Commonly known as a heart attack, is the interruption of
blood supply to part of the heart, causing heart cells to die.
• This is most commonly due to occlusion (blockage) of a
coronary artery following the rupture of a vulnerable
atherosclerotic plaque, which is an unstable collection of
lipids (fatty acids) and white blood cells (especially
macrophages) in the wall of an artery.
• The resulting ischemia and oxygen shortage, if left
untreated for a sufficient period of time, can cause damage
or death of myocardium.
• Classical symptoms of acute myocardial infarction include
sudden chest pain (typically radiating to the left arm or left
side of the neck), shortness of breath, nausea, vomiting,
palpitations, sweating and anxiety.
• Immediate treatment for acute myocardial infarction
includes aspirin, sublingual nitroglycerin & oxygen.
MANAGEMENT OF PATIENT WITH ACUTE MI
Recognize problem
(chest pain, patient states he/she is having an anginal attack)
Discontinue dental treatment
Activate office emergency team
P— Position patient comfortably
A- B- C- Assess airway, breathing, and circulation
D— Provide definitive management
HISTORY OF ANGINA PRESENT
NO HISTORY OF
ANGINA
Administer vasodilator and O, (up to 3 doses)
IF PAIN
Activate EMS, STAT
administer O2 and
RESOLVES
consider nitroglycerin
Consider future dental
Administer Aspirin
Treatment modifications
Manage pain (parentral opiods, N2O-O2)
Monitor and record vital signs
Prepare to manage complications
(eg: sudden cardiac arrest)
Stabilize and transfer to hospital ICU
Cardiac Arrest
• Cardiac arrest or circulatory arrest is the cessation of
normal circulation of the blood due to failure of the heart
to contract effectively and if this is unexpected can be
termed a sudden cardiac arrest.
• Cardiac arrest is different from (but may be caused by) a
heart attack, where blood flow to the muscles of the heart
is impaired.
• Arrested blood circulation prevents delivery of oxygen to
the body. Lack of oxygen to the brain causes loss of
consciousness, which then results in abnormal or absent
breathing. Brain injury is likely if cardiac arrest goes
untreated for more than five minutes.
• Cardiac arrest is a medical emergency that in certain
situations is potentially reversible if treated early.
• The treatment for cardiac arrest is cardiopulmonary
resuscitation (CPR) to provide circulatory support,
followed by defibrillation.
Causes
• Coronary heart disease is the leading cause of sudden
cardiac arrest. 60-70% is related to coronary heart disease.
• A number of other cardiac abnormalities can increase risk
including: cardiomyopathy, cardiac rhythm disturbances,
hypertensive heart disease, congestive heart failure.
• Non-cardiac : Trauma, non-trauma related bleeding (such
as gastrointestinal bleeding, aortic rupture, and intracranial
hemorrhage), overdose, drowning & pulmonary embolism.
Management
CA is managed in five stages
1. initial response
2. basic life support
3. advanced life support
4. post resuscitation care
5. long term management
Choking and Foreign Body Airway Obstruction
• Choking is the physiological response to sudden airway
obstruction. Obstruction may be partial or complete.
• Foreign body airway obstruction (FBAO) causes asphyxia
occurring very acutely, with the patient often unable to
explain what is happening to them and with rapid loss of
consciousness and death if first aid is not undertaken
quickly and successfully. Immediate recognition and
response is of the utmost importance.
• Any object routinely placed into or removed from the oral
cavity during dental or surgical procedures can be aspirated
or swallowed. These items can include teeth, restorations,
restorative materials, instruments, implant parts, rubber
dam clamps, gauze packs and impression materials. The
possibility of swallowing or aspirating an object is
increased by the common practice of placing the patient in
a supine position or semi-spine position.
• Other factors that may increase the possibility of aspiration
include age (a decreased gag reflex in elderly patients),
medical conditions (such as stroke, dementia and
Parkinson's disease), use of local anesthetics and altered
states of consciousness associated with intravenous
sedation.
• The consequences of aspirating a foreign object or material
can range from immediate obstruction of the airway to
long lasting pulmonary complications. Early complications
can include hypoventilation of the distal lung segment with
subsequent atelectasis and hypoxia. Later complications
can include infection, such as lung abscess or pneumonia,
and atelectasis.
Management
• Action depends upon the severity of the situation and the
adequacy of the cough. It may be classified as:
1.
Mild
2.
Severe but conscious
3.
Severe and unconscious
• In mild airway obstruction encourage him to keep
coughing but more dramatic action is unnecessary.
• If there is severe airways obstruction but he is conscious,
give 5 blows to the back.
• Stand to the side and slightly behind the victim, preferably
to the left if you are right handed and the right if you are
left handed.
• Support the chest with one hand and lean the victim well
forwards so that when the obstructing object is dislodged it
comes out of the mouth rather than goes further down the
airway.
• Give a sharp blows between the scapulae with the heel of
the hand.
• After each blow, reassess the patient to see if the foreign
body has moved.
• If the airways are still obstructed, repeat the blow and reassess until 5 blows have been delivered. If this does not
work, use the Heimlich maneuver (or abdominal thrust).
HYPERTENTION
• Elevated blood pressure for long time period (chronic) due
to unknown cause is called essential hypertension.
• Mild to moderate hypertension with systolic pressure of
less than 200 or diastolic pressure of less than 110 is
usually not a problem to the performance of ambulatory
oral surgical care, but more than this value if present in a
patient who needs elective oral surgery, then blood
pressure is first controlled and surgery is postponed.
• Care includes anxiety reduction protocol and monitoring of
vital signs.
• Epinephrine containing local anesthetics should be used
cautiously.