ภาวะฉุกเฉินทางการแพทย์ (Medical
Emergencies) ในคลินิกทันตกรรม
• การป้องกัน (Prevention)
• การจัดการ (Management)
• Emergencies in dental practice can
occur to any person, any time.
• How to manage, it is the most difficult
thing at time occurred.
• The majority emergency is
syncope.
Others
–
–
–
–
–
–
–
allergic reaction
angina pectoris
postural hypotension
seizures
asthmatic attack
hyperventilation
hypoglycemia
•
•
•
•
•
anaphylactic reaction
cerebrovascular accident
adrenal insufficiency
thyroid storm
etc
Composition of consciousness
–
–
–
–
Brain
O2
Glucose
Effective hemodynamic
Fact … of human brain
• Uses O2 approx. 20% of total O2
• Uses glucose approx. 65% of total glucose
• Uses approx. 20% of total circulation/min
(750 ml.min.)
Balance mechanism of :
• Hemodynamic
• Respiration
• Metabolism
• Neurologic
Caused from impair ……..
– Hemodynamic
– Respiration
– Metabolism
– Neurologic
How to avoid these complications?
•
•
•
•
Prevention is the best
Good history taking
Good preoperative preparation
Good operative controls
Possible causes of unconsciousness in
the dental office
• Vasodepressor
syncope
• Drug administration
/ingestion
• Orthostatic
hypotension
• Epilepsy
• Hypoglycemic reaction
• Acute adrenal
insufficiency
• Acute allergic reaction
• Acute myocardial
infarction
• Cerebrovascular
accident
• Hyperglycemic
reaction
• Hyperventilation
syndrome
Alteration of consciousness
•
•
•
•
•
•
•
Cerebrovascular accident (CVA)
Seizures
Hypoglycemia / Hyperglycemia
Adrenal insufficiency
Thyroid storm
Hyperventilation
Drug overdose
Syncope is the most common
occurred.
Factors influence
• Stress and anxiety
• Health status
• Drugs
How syncope occur?
In normal : circulation compensation
mechanism play role in correction
of deficiency O2 supply to the
brain.
How syncope occur?
In syncope : circulation
compensation mechanism fail to
increase O2 need from the brain
Signs for syncope
Early :
Feeling of warmth
Loss of color : pale or ashen=gray skin tone
Heavy perspiration
Complaints of feeling “bad” of “faint”
Nausea
Blood pressure approximately baseline
Rapid heart rate
Signs for syncope
Late :
–
–
–
–
–
–
–
–
Pupillary dilation
Yawning
Hyperpnea
Cold hands and feet
Hypotension
Bradycardia
Dizziness
Loss of consciousness
Critical consideration
• Timing of detection and
correction
• Maintain O2 level to the brain
: Airway, Breathing,
Circulation (ABC - Basic life
support)
Orthostatic hypotension
•
•
•
•
Failure of the baroreceptor reflex
Loss of compensate mechanism
Reflex bradycardia
Loss of consciousness
Drugs producing orthostatic
hypotension
Category
Generic name
Proprietary name
Antihypertensives
Guanethidine
Ismelin
Phenothiazines
Chlorpromazine
Thioridazine
Doxepin
Amitriptyline
Imipramine
Thorazine
Mellaril
Sinequan
Elavil
Tofranil
Presamine
Demerol
Morphine
Dopar
Larodopa
Tricyclic
antidepressants
Narcotics
Meperidine
Morphine
Antiparkinson drugs Levodopa (L-dopa)
Unconsciousness
Assessment : Check for Breathing
– Look the chest to rise and fall
– Listen for air escaping during
exhalation
– Feel for the flow of air
Unconsciousness : no response to stimuli
P - position : SUPINE
Call for help : EMS activation
A, B = Airway (head tilt - chin lift)
Artificial Assisted Breathing (if no self
respiration)
C = check circulation
Carotid pulse absent
Carotid pulse present
Check medical history
Vital signs
Recovery
Vasodepressor
syncope
Activate EMS
unrecovery
Orthostatic
hypotension
Initiate CPR
Immediate
transportation
Sequence of BCLS
• Assessment
• EMS Activation
• ABCs of CPR
• D of Defibrillation
ABCs of CPR
• Airway
• Breathing
• Circulation
Airway
• Position the victim
• Rescuer position
• Open the Airway
– Head Tilt - Chin Lift Maneuver
– Jaw Thrust Maneuver
– Recommendations for Opening
the Airway
Classification of causes of
unconsciousness by mechanism
Mechanism
Inadequate delivery
of blood or oxygen
to the brain
Clinical example
Acute adrenal
insufficiency
Orthostatic
hypotension
Vasodepressor syncope
Classification of causes of
unconsciousness by mechanism
Mechanism
Systemic or local
metabolic
deficiencies
Clinical example
Acute allergic reaction
Drug ingestion and
adminstration
Nitrites and nitrates
Diuretics
Sedatives-narcotics
Local anesthetics
Hyperglycemia
Hyperventilation
Hypoglycemia
Classification of causes of
unconsciousness by mechanism
Mechanism
Direct or reflex
effects on nervous
system
Clinical example
Cerebrovascular
accident
Convulsive episodes
Psychic mechanisms
Emotional disturbances
Hyperventilation
Vasodepressor syncope
Causes of chest pain
Cardiac related
• Angina pectoris
• Myocardial infarction
Non-cardiac related
•
•
•
•
•
•
•
•
Muscle strain
Pericarditis
Esophagitis
Hiatal hernia
Pulmonary embolism
Dissecting aortic aneurysm
Acute indigestion
Intestinal “gas”
Chest pain is one of the major
clinical clues to the presence of
significant heart disease.
Definition of Terms
“Atherosclerosis” is a special type of thickening
and hardening of medium - sized and large
arteries because of deposits of a fatty substance.
• is an ongoing process
• is a reactive biologic response of arteries to the
forces being generated by the flow of blood.
Atherosclerosis is the major
factor underlying all forms
cardiovascular disease.
Normal structure
Development of atherosclerosis
Proliferative
change
Development of atherosclerosis
Lipid
deposition
The development of ACS
Early plaque formation
Significant plaque formation
Plaque rupture
Thrombus
Coronary artery disease is the
presence of atherosclerosis in the
coronary arteries.
• Angina pectoris
• Myocardial infarction
Angina is a transient discomfort
(usually less than 15 minutes) due to
a temporary lack of adequate blood
supply to the heart muscle.
Myocardial infarction is defined
as death of heart muscle
(myocardium) as the result of
prolonged inadequate blood flow
and oxygen delivery.
Acute coronary syndromes
encompasses symptomatic condition
resulting in an inadequate blood
supply to the heart; including
unstable angina and AMI.
AMI (heart attack) is defined as
death of heart tissue due to
blockage of a coronary artery
caused by atherosclerosis and
thrombus formation.
Unstable angina
• Angina that is continuing, prolonged or
occurring at rest.
• Represents a syndrome that lies between
angina pectoris and AMI.
Unstable
Angina pectoris --------------> AMI
Angina
Risk factors : Heart attack
• Risk factors that cannot be changed
Age
Heredity
Gender
Race
• Risk factors that can be changed
Cigarette smoking
High blood pressure
High blood
cholesterol level
Physical inactivity
Diabetes
Obesity
Excessive stress
Diagnosis
Electrocardiogram (EKG)
Exercise stress test
Echocardiogram
Coronary angiography
Treatment
1. Coronary artery bypass graft surgery (CABGS)
2. Medical therapy
3. Percutaneous Transluminal Coronary
Angioplasty (PTCA) หรื อ Percutaneous
Coronary Intervention (PCI)
Drugs and bleeding in patient with CAD
•
•
•
•
Aspirin
Plavix
Ticlid
Coumadin
Angina pectoris
• Potential problem related to dental care
1. Stress and anxiety related to dental visit may
precipitate angina attack
2. Myocardial infarction
3. Sudden death
Angina pectoris
• Prevention of complication
1. Detection of patient
2. Referral of patient for medical evaluation and
treatment
• Prevention of complication
3. Known case with medical treatment for angina
– Stress reduction protocol
• Premedication
• Open and honest communication
• Morning appointments
• Short appointments
• Nitrous oxide - oxygen
– Avoid excessive amounts of epinephrine
Emergency action plan for a person with signals of heart attack
Unknown case of CAD
Known case of CAD
Recognize the signals of a heart
attack
Recognize the signals of heart attack
Stop activity and sit or lie down
Wait about 5 minutes to see if
the symptom go away. If the
pain persists :
Stop activity and sit or lie down
Take 1 nitroglycerin tablet at a time
at 3 - to 5 minutes intervals to
maximum total dose of 3 tablets. If
pain persists.
Transport patient to hospital
• Potential problem related to dental care
1. Cardiac arrest
2. Myocardial infarction
3. Angina pectoris
4. Congestive heart failure
5. Bleeding tendency secondary to anticoagulant
• Prevention of complication
1. No routine dental care until at least 6 months
after infarction
2. Medical consultation
– Current status
– Medication used
3. Stress reduction protocol
– Premedication
– Open and honest communication
– Morning appointment
– Short appointment
– Nitrous oxide - oxygen
4. Avoid excessive amounts of epinephrine
5. Check PT (Anticoagulant medication)
Management of Acute Myocardial Infarction
Step 1. Diagnosis
Administer nitroglycerin
2. Initiate BLS
3. Summon medical assistance
4. Administer oxygen and monitor vital signs
5. Relive pain
Morphine
Nitrous oxide - oxygen
6. Transport patient to hospital
ผูป้ ่ วยชายอายุ 68 ปี มาด้วยมีส่วนแหลมคมของฟัน
กรามบนซ้าย เป็ นฟันที่รับการรักษาคลองรากฟั นและ
มีตวั ฟันแตกออก วางแผนการรักษาโดยการถอนฟัน
จากการซักประวัติ ผูป้ ่ วยเป็ นโรคหลอดเลือดหั วใจ
ได้รับการรักษาโดยการทาบอลลูน และรับประทานยา
อยูเ่ ป็ นประจา
Medical Problem List
1. Coronary artery disease :
double - vessel
Status : post PCI พ.ค. +
มี.ค. 46
at present : asymptomatic
2. DM : controlled
3. HT : controlled
4. Old CVA : Left
hemiparesis 5 yrs ago
at present : complete
recovery
5. Mild renal insufficiency
6. Mild late onset asthma
Current medication
1. Aspent gr. V
2. Plavix
3. Plendil
4. Minidiab
5. Bestatin
6. Singvalac
1 x 1 orally pc.
1 x 1 orally pc.
1 x 2 orally pc.
1 x 1 orally pc.
1 x 1 orally pc.
1 x 1 hs.