HOSPITAL DENTISTRY:
Emergency
 An unforeseen combination of
circumstances or the resulting state
that calls for immediate action
Medical Emergency
 An acute injury or illness that poses
an immediate risk to a person’s life
or long term health
Emergency Condition
 A condition manifesting itself by acute
symptoms of sufficient severity
(including severe pain) such that the
absence of immediate medical
attention could reasonably be expected
to result in placing the individual’s
health (or the health of an unborn
child) in serious
Prevention
 Thorough medical history
 Update information regularly and
review before each visit
 Physical examination
- Baseline vital signs
Preparation
 Current BLS/ACLS certification
 Didactic and clinical courses in
emergency medicine
 Periodic emergency drills
 Telephone numbers of EMS or other
appropriately trained health-care
providers
 Emergency drug kit and equipment
and the knowledge to properly use all
items
Emergency drug kit
ADA suggests that the following drugs should
be included in the emergency kit:
1. Oxygen
2. Epinephrine 1:1000 (injectable)
3. Nitroglycerin (sublingual tablet or
aerosol spray)
4. Histamine blocker (IV)
5. Bronchodilator (asthma inhalersalbutamol)
6. Aspirin
7. Oral carbohydrate
8. Other drugs
 Glucagon
 Atropine
 Ephedrine
 Corticosteroids
 Morphine
 Naloxone
 Nitrous oxide
 Injectable benzodiazepam
 Flumazenil
Syncope
 Define as a short loss of consciousness
and muscle strength, characterized by
a fast onset, short duration and
spontaneous recovery
 Causes:
 HEAD (CNS Causes)
H: Hypoxia/hypoglycemia
E: Epilepsy
A: Anxiety
D: Disorders of brain stem

HEART (CVS Causes)
H: Heart attack (MI)
E: Embolism (PE)
A: Aortic Stenosis/Acute
Coronary Syndrome
R: Rhythm Abnormalities (drug
induced, Afib)
T: tachycardia

VESSELS (vascular and other
causes)
V: Vasovagal causes (common
faint)
E: Electrolyte Abnormalities
S: Situational (cough, sneeze,
micturation)
S: Subclavian Steal Syndrome
E: ENT causes
(Glossopharyngeal neuralgia)
L: Low systemic vascular
resistance (Addison’s disease,
DM Nephropathy)
S: Sensitive carotid sinus/Sick
sinus syndrome/Substance
Abuse
Pre-syncope
Early
 Feeling of warmth
 Loss of skin color
 Heavy perspiration
 Complaints of feeling ill
 Nausea
 Hypertension
 Tachycardia
Late
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Pupillary dilatation
Hyperpnea
Cold hands and feet
Hypotension
Bradycardia
Visual disturbances
Dizziness
Breathing (irregular, jerky and
gasping)
Dilated pupils (death like appearance)
Episodes of convulsion
Bradycardia (<50 beats/min)
Weak thread pulse
Loss of consciousness
Partial or complete airway obstruction
Post-syncope
 Pallor
 Nausea
 Weakness
 Sweating
SYNCOPE MANAGEMENT
1. Position
 Supine position with brain and
heart at the same level with
feet elevated slightly (10-15
degree)
2. Basic Life Support
3. Definitive Management
 Monitor vital signs
 Administer aromatic ammonia
 Administration of atropine (0.1
mg/ml)
*If with delayed recovery, seek medical
assistance.
Seizure
 A paroxysmal disorder of cerebral
function characterized by an attack
involving changes in the state of
consciousness, motor activity or
sensory phenomena
 Usually sudden in onset and of brief
duration
Epilepsy
 A chronic brain disorder of various
etiologies characterized by recurrent
seizures
Seizure Classification
1. Partial – seizure activity originates in
one part of the brain
 Simple
 Complex
2. Generalized – seizure activity involved
entire brain
 Absence
 Myoclonic
 Tonic clonic
 Tonic
 Atonic
Seizure Triggers
 Missed medication (#1 reason)
 Stress/anxiety
 Hormonal changes
 Dehydration
 Lack of sleep/extreme fatigue
 Photosensitivity
 Drug/alcohol use; drug interaction
Seizure Common Symptoms
 Blank staring
 Chewing
 Fumbling
 Wandering
 Shaking
 Confused speech
Seizure Management
 Self-limiting emergency
 Position: supine with patient placed on
flat surface
 Remove dangerous objects from the
mouth and around the patient
 Loosen any tight clothing
 Avoid restraining the patient
 In case the ictus fails to subside
within 10 minutes, declare status
epilepticus and proceed with definitive
care
Seizure Definitive Treatment
 Diazepam 10mg IV (2mg/min) repeat
every 10 minutes
 Phenorbarbital (100-200 mg/min) IV
Hypoglycemia
 Clinical syndrome in which low serum
(or plasma) glucose levels lead to
symptoms of sympatho-adrenal
activation
Common Symptoms of Low Blood Sugar
 Trembling
 Pounding Heart
 Sweating
 Hunger
 Numbness or tingling
 Sleepiness
 Irritability
 Headache
Common Symptoms of Very Low Blood Sugar
 Confusion
 Blurred Vision
 Difficulty in speaking
 Seizures or coma
Hypoglycemia Management
 Glucose and sugar-containing
beverages administered orally to
conscious patients with rapid effect
 Alternatively, milk, candy bars, fruits,
cheese, and crackers may be adequate
for mild cases
 IV dextrose is indicated for severe
hypoglycemia in patient with altered
consciousness and during restriction of
oral intake
 An initial bolus, 20-50 ml of 50%
dextrose, should be given immediately
 Glucagon 1 mg IM (or SC) is an
effective initial therapy for severe
hypoglycemia patients unable to
receive oral intake or in patients
whom IV access cannot be secured
immediately
Trauma
 Refers to damage, impairment or
external violence producing injury or
degeneration
 Trauma of the oral and maxillofacial
region occur frequently
 Comprises 5% of all injuries for which
people seek treatment
 Among all facial injuries, dental
injuries are the most common, of
which crown fractures and luxation
occur most frequently
A traumatic injury in the maxillofacial region
can result in:
 Fractures of the jaws
 Fractures of the teeth
 Soft tissues injuries
 Injuries to vital structures
Trauma Management
 Avoid patient movement before
determining extent of trauma
 First should be given for the injuries
occurred
 Airway:
-

Chin lift
Jaw thrust
Manually move the tongue
forward
- Maintain cervical
immobilization
Hemorrhage control:
- Maxillofacial bleeding
 Direct pressure
- Nasal bleeding
 Direct pressure
 Anterior and posterior
packing
Chest Pain
 Commonly includes:
- Angina Pectoris
- Myocardial Infarction
Angina Pectoris
 Characterized by thoracic pain, usually
substernal; precipitated chiefly by
exercise, emotion, or a heavy meal;
relieved by vasodilator drugs and a
few minutes rest. It is also a result
of moderate inadequacy of coronary
circulation
 Produced when myocardial blood
supply cannot be sufficiently increased
to meet the increased oxygen
requirement that results from
coronary artery disease
Angina
1.
2.
3.
4.
Pectoris Management
Recognizes the problem
Discontinue dental treatment
Position patient comfortably
ABC – access airway, breathing and
circulation
5. Definitive management
 If history of angina exists:
 Administer vasodilator
O2
 If pain resolves:
 Consider future dental
treatment modification
Monitor vital signs

No history of angina:
Administer O2 and
consider nitroglycerin
Monitor and record
Acute Myocardial Infarction
 A clinical syndrome caused by a
deficient coronary arterial blood
supply to a region of myocardium that
results in cellular death and necrosis
 Usually characterized by sever and
prolonger substernal pain similar to
but more intense and of longer
duration than the angina pectoris
 Should be suspected if:
- First episode of chest pain
suggestive of acute MI that
occurs either at rest or with
ordinary activity. It may
develop during dental
treatment especially if patient
is dental phobic
- Change in previous stable
pattern of pain which may be
increased in frequency of
severity
- Chest pain is suggestive with
MI in a patient with known
CAD if relieved by rest or
nitroglycerin
Acute MI Management
1. Recognizes the problem
2. Discontinue dental treatment
3. Position patient comfortably
4. ABC – access airway, breathing and
circulation
5. Definitive management
 Presumptive Disease: Acute MI
Administer O2,
consider nitroglycerin
Administer aspirin
Manage pain
(parenteral opioids)
Monitor and record
vital signs
Prepare to manage
complications (e.g.
cardiac arrest)
Stabilize and transfer
to hospital emergency
department
No history of angina:
Administer O2 and
consider nitroglycerin
Monitor and record
STEP BY STEP OF HEIMLICH
 Lean the person forward slightly and
stand behind him or her
 Make fist with one hand
 Put your arms around the person and
grasp your fist with your other hand
near the top of the stomach, just
below the center of the rib cage
 Make a quick hard movement inward
and upward
Airway Obstruction
 Causes:
- Foreign body (usually food)
- Infection of post-traumatic
hematoma
- Obstruction by the tongue
- Trauma
 Presentation:
- Stridor
- Impaired or absence phonation
- Choking and respiratory
distress
- Angioedema
- Fever
- Evidence of trauma
*If the patient is unconscious, perform BLS.
Management
- Direct and rapid relief of obstruction
to prevent cardiopulmonary arrest and
anoxic brain damage
- Perform head-tilt-chin-lift maneuver
if cervical spine trauma is not
suspected
- Perform jaw thrust maneuver if
cervical spine trauma is suspected
- Attempt to ventilate the patient with
bag-valve-mask apparatus
- Perform the Heimlich maneuver (sub
diaphragmatic abdominal thrust)
repeatedly until the object is expelled
from the airway
- If the situation cannot be manage,
the patient should be referred to a
nearest hospital
Management
 Discontinue the dental procedure and
allow the patient to assume an
upright position
 Establish and maintain a patent
airway and administer Beta2 agonists
via inhaler or nebulizer
 Administer oxygen if possible
 If no improvement is observed and
symptoms are worsening, administer
epinephrine subcutaneously (1:1,000
solution, 0.01 mg/kg of body weight
to a maximum dose 0.3mg)

Asthma
 A clinical state of hyper reactivity of
the tracheobronchial tree,
characterized by recurrent paroxysms
of dyspnea and wheezing
Signs and Symptoms
 Feeling of chest tightness
 Dyspnea
 Tachypnea
 Cough
 Use of accessory/respiratory muscles
 Agitations
MANIFESTATIONS AND MANAGEMENT OF
LOCAL ANESTHTICS OVERDOSE
Mild Overdose
 Manifestations: Talkativeness, slurred
speech, anxiety, confusion

Management:
1. stop administration of local
anesthesia
2. monitor vital signs
3. observe for 1 hour
Moderate Toxicity
 Manifestations: Slurring speech,
nystagmus, tremor, headache,
dizziness, blurred vision, drowsiness
 Management:
1. stop administration of LA
2. place the patient in supine
3. monitor vital signs
4. administration of oxygen
5. observe for 1 hour
Severe Toxicity
 Manifestations: seizures, cardiac
arrhythmia or arrest
 Management:
1. Place the patient in supine
position
2. If seizure occurs, protect the
patient from nearby objects
3. Suction the oral cavity if
vomiting occurs
4. Seek for medical assistance
5. Monitor vital signs
6. Administer oxygen
7. Start IV infusion
8. Administer diazepam 5-10mg
slowly
9. Provide BLS
10. Transport patient to a nearby
hospital
Epinephrine (vasoconstrictor) overdose
reaction:
 Available concentrations are
1:50000, 1:00000, 1:200000
 The optimal concentration for the
prolongation of anesthesia with
lidocaine is 1:250000
 Maximal dose:
- Healthy adult (0.2 mg)
- Cardiac patient (0.04 mg)


Clinical Manifestations
- Signs:
 Rise in blood pressure
and heart rate
- Symptoms:
 Anxiety
 Restlessness
 Perspiration
 Dizziness
 Weakness
 Pallor
 Palpitation
Management:
- Terminate the dental
procedure
- Position the patient in upright
position
- Reassure the patient
- BLS, if indicated
- Monitor vital signs
- Summon medical assistance
- Administer oxygen
Opioids
 Although opioids have been used as an
effective analgesic drug, most of the
time it has been used as an abusive
product
 Opioid toxicity can result in:
- Respiratory depression
- Depressed level of
consciousness
- Miosis
 Treatment:
- Gastric lavage
- Antidote (naloxone
hydrochloride, initial dose of
2mg IV)
Alcohol
 The toxicity of alcohol is dose related
 Blood levels >100 mg/dl are
associated with ataxia
 At 200mg/dl, patients are drowsy and
confused


At levels >400 mg/dl, respiratory
depression is common and death is
possible
Treatment:
- Administration of 100 mg
thiamine IV
- Treat hypoglycemia with 50%
dextrose solution
- Provide oxygen, as needed
General Anaphylaxis
 Acute life threatening condition
 Reactions develop rapidly 5-30
minutes
 Signs and symptoms of generalized
anaphylaxis are highly variable

Four major clinical symptoms are:
- Skin reactions
- Smooth muscle spasm
- Respiratory distress
- Cardiovascular collapse

Management:
- Terminate dental procedure
and stop administration of all
drugs presently in use
- Position the patient
comfortably
- BLS, if indicated
- Monitor vital signs

Definitive Management:
- No CVS or respiratory
involvement
 Administration of oral
or IV antihistamine
- CVS or respiratory involvement
 Reposition the patient
 Administration of
epinephrine
 Administration of
antihistamine
To conclude:
 The first step in management of
dental emergencies is to prevent the
occurrence
 With proper knowledge medical
emergencies and related complication
can be easily prevented
 “When you prepare for the
emergency, the emergency ceases to
exist.”