Medical Emergencies in Dentistry: Drugs, Syncope, Shock, and Stroke

Anaphylaxis (Severe allergic reaction)

Epinephrine

Angina heart failure or myocardial infarction

Nitroglycerin

Mild to moderate allergic reaction

Diphenhydramine

Mild allergy in children

Chlorpheniramine

Asthma attack

Albuterol

Myocardial infarction

Aspirin

Hypoglycemia

Oral carbohydrate (glucose)

Seizures or hyperventilation

Lorazepam

Anaphylaxis

Hydrocortisone

many applications

Oxygen

Rapid onset short duration. Reduces hypotension bronchospasm and laryngeal edema prevents histamine release and other chemical mediators avoid use in patients with severe hypertension or heart disease unless immediately life threatening.

Epinephrine action

Dilates coronary blood vessels to provide additional oxygen to the heart muscle. Rapid onset. Contraindicated if systolic pressure falls below 90, or if the patient is taking erectile dysfunction medication.

Nitroglycerin action

histamine blocker

Diphenhydramine action

histamine blocker

Chlorpheniramine action

Bronchodilator quick onset, long duration

Albuterol action

Reduces overall mortality from myocardial infarction if administered early. Contraindication allergy.

Aspirin action

Increase blood sugar

Oral carbohydrate (glucose) action

Anti-convulsant

Lorazepam action

Prevents recurrence of anaphylaxis manage adrenal crisis, reduces histamine release

Hydrocortisone action

Contraindicated with hyperventilation

Oxygen action

The most common medical emergency in the dental office

Syncope

Physiologic response to stress most likely type of syncope in the dental office

Vasovagal (neurocardiac) syncope

Non-cardiac syncope may be due to seizures, orthostatic hypotension (a drop in blood from supine -> upright), hyperventilation, or other occurrences.

Non-Cardiac syncope

May occur as a result of an underlying heart disorder, arrhythmia, tachyarrhythmia (fast heart rate), Brady arrhythmia (slow heart rate) or pacemaker malfunction. Potentially fatal.

Cardiac syncope

Immediately suspend all dental procedures. If prodromal symptoms are present. If consciousness is lost, place the patient in a supine position with legs slightly elevated so that blood may return to the brain.

Vasovagal syncope treatment

Episodes that are at high risk for the first 24 hours following an event, requiring patient escort for the remainder of the day.

Secondary syncope

No longer recommended for use.

Ammonia inhalants

The patient should continue to an emergency facility for a definitive diagnosis of underlying conditions.

Non-neurocardiac syncope

A condition where there is not enough oxygenated blood delivered to body tissues to support their metabolic needs.

Shock

The most common type of shock, caused by severe hemorrhage or dehydration.

Hypovolemic shock

A type of shock resulting from the heart's inability to pump blood effectively.

Cardiogenic shock

A type of shock that includes anaphylactic (allergy), septic (due to infection), and obstructive shock.

Distributive shock

A type of shock characterized by severe hypotension.

Obstructive shock

Stop dental treatment immediately, place the patient in a supine position, monitor vital signs, activate EMS response, treatment depends on type of shock.

Treatment of shock

Occurs when the patient breathes faster and/or deeper than the body needs, expelling excess carbon dioxide.

Hyperventilation syndrome

Between 22 and 40 respirations per minute.

Respiration rate in hyperventilation

Include being female aged 30 to 40, high altitudes, pregnancy, CNS stimulating drugs, aspirin toxicity, fear, and anxiety.

Risk factors for hyperventilation

Causes blood pH to rise to 7.5 or higher, leading to vasoconstriction, reduced cardiac output, heart palpitations, and chest pain.

Physiological effects of hyperventilation

Impaired coordination, balance, perceptive tasks, dizziness, impaired vision, lightheadedness, and muscle spasms due to hypocalcemia.

Symptoms of hyperventilation

Remain calm, loosen constrictive clothing, guide the patient to slow their breathing, monitor vital signs, and DO NOT ADMINISTER OXYGEN.

Treatment of hyperventilation

May be necessary if underlying conditions exist or if other conditions are suspected.

Transportation by EMS for hyperventilation

May be administered intramuscularly if symptoms do not subside (not by hygienist).

Lorazepam administration

Include abdominal surgery, immobilization, pregnancy, and deep vein thrombosis.

Pulmonary embolism risk factors

Temporary changes in behavior due to abnormal electrical discharges in the brain.

Seizure disorders

Can include extreme stress, hypoxia, dropping blood glucose, sudden elevations in body temperatures, brain damage, and genetic tendencies.

Causes of seizures

Overgrowth of gum tissue that may be caused by medications taken by patients with seizure disorders.

Gingival hyperplasia

Brief, non-motor events occurring in children and young people, causing a lapse in awareness and typically lasting only a few seconds.

Absence seizures

Can be mistaken for 'day-dreaming' due to their brief nature.

Misinterpretation of absence seizures

Dental treatment should stop during the duration of the episode, all instruments should be made safe, vital signs should be monitored, treatment may continue at the conclusion of the seizure if the patient has no ill effects.

Treatment during seizure

During the prodromal stage some people can tell when a seizure is on its way. They may notice some early signs hours or even days before the seizure starts.

Prodrome stage

Mood changes, anxiety, feeling lightheaded, difficulty sleeping, difficulty staying focused, behavior changes.

Common signs of prodrome stage

the patient experiences muscular contractions and relaxation producing convulsions. The jaw will remain clenched. Blood or foam may appear at the mouth, and soft tissue injuries may occur. This phase usually lasts 2 to 5 minutes.

Clonic phase

occurs after the active (ictal) part of the seizure. CNS depression occurs when urinary and or fecal incontinence may occur, the patient may awake confused, fatigued and may or may not remember having a seizure.

Post-ictal phase

Confusion, lack of consciousness, tiredness (fatigue), exhaustion, headache, loss of bladder or bowel control, fear and anxiety, frustration, shame or embarrassment, thirst, nausea, sore muscles, weakness in parts of the body, injury (head, cuts, broken bones).

Common signs of post-ictal phase

Clinicians should be alert for impending seizures such as mood changes, reports of aura or sudden losses of consciousness. At the first sign of a seizure, immediately stop dental treatment and make instruments safe, move hazards away from the patient.

Treatment for generalized tonic seizures

Note the time of the beginning of the seizure, do not attempt to take the patient out of the dental chair or put anything in their mouth. Do lower the chair to minimize damage if the patient falls.

Emergency procedures during seizure

If the patient becomes cyanotic or the seizures last more than three minutes, contact EMS. Oxygen may be given, vital signs should be monitored, do not place anything in the patient's mouth or forcefully restrain.

Cyanotic patient management

During the post ictal stage monitor airway and observe for signs of respiratory arrest. Patients may be confused, disoriented and require reassurance and calm.

Post-ictal stage monitoring

Patients recovering from a tonic clonic seizure should be released into the care of their emergency contact and should not drive themselves.

Release after seizure

The difference between a general tonic clonic seizure and a more serious 'status epilepticus' or 'grand mal' would be the ________________

length of the seizure.

The normal duration of a tonic clonic seizure is 2 to 5 minutes, while a status epilepticus may persist for hours or days, and may result in death due to dysrhythmias, elevated blood pressure, cardiac arrest, and cerebral hypoxia.

Duration of tonic clonic seizure

Treat as a GCTS, after 3 minutes without resolution, contact EMS.

Treatment for status epilepticus

CVAs can be ischemic or hemorrhagic.

Cerebrovascular accident (CVA)

Ischemic strokes are occlusive, meaning there is a blockage in a cerebral blood vessel. The blockage deprives surrounding tissue (called the penumbra) of oxygen and glucose and must be treated quickly to avoid lasting complications.

Ischemic stroke

Hemorrhagic strokes occur as a result of rupturing of blood vessels in the brain. This type is less common, about 15% of the time.

Hemorrhagic stroke

Hypertension, anticoagulation medications, tumors, substance abuse can cause a hemorrhagic stroke.

Causes of hemorrhagic stroke

Hemorrhagic strokes have higher mortality rates than occlusive strokes.

Mortality rates of strokes

Altered level of consciousness, unequal pupils dilation, confusion, notable change in balance or coordination, vision changes, speech changes including impaired speech (dysphasia) or the inability to speak at all (aphasia), difficulty swallowing, deviation of the tongue to the side, drooling, weakness on one side of the body or face, nausea, vomiting, severe headache.

Ischemic stroke signs and symptoms

Similar to ischemic stroke but come on more suddenly. Acute headache, high blood pressure, may have neck pain or stiffness, pupillary malalignment, nausea, vomiting, altered consciousness.

Hemorrhagic stroke signs and symptoms

Ask the patient to smile and look for weakness on one side of the face. Ask the patient to hold their arms out to the side with palms up and eyes closed for 10 seconds, check for drooping in one arm. Ask the patient to repeat a sentence and look for difficulty in speech (dysphasia). If any of the above are abnormal, the patient may be having a stroke.

Stroke assessment

Contact EMS immediately and note time of onset and symptoms. Position semi supinely, do not administer oxygen unless there are signs of hypoxia. Monitor vital signs. Aspirin may improve outcomes, but it is not advised for anyone other than the health care provider in the emergency department to administer medication to suspected stroke patients.

Stroke emergency response

May mimic stroke (without facial drooping).

Hypoglycemia

Patients with stable angina are generally under the care of a physician and are controlling their condition with a calcium channel blocker, beta adrenergic blocking agents, and nitrates. The angina may be brought on by physical activity, stress, cold weather, or large meals. Angina presents as a dull constant pressure lasting from 1 to 15 minutes and responds positively to rest and/or nitroglycerin. Angina is stable if the patient has had no increase in frequency of symptoms within the last 60 days and no changes to what precipitates the attack.

Stable angina

Should be scheduled for short visits, to minimize stress.

Dental treatment for stable angina

Angina is considered unstable if it presents with one of the following three conditions: angina occurs at rest or with minimal exertion, and lasts 20 minutes or more; the onset is new with severe pain; the pain is more severe and more prolonged, over 20 minutes or more frequent than angina experience previously. Nitroglycerin may or may not relieve the pain. Patients with unstable angina are at high risk for Acute Myocardial Infarction (Heart attack).

Unstable angina

Patients with unstable angina should only receive minimal dental care with medical clearance. No vasoconstrictors in local.

Dental care for unstable angina

If acute myocardial infarction is suspected, stop treatment immediately if the patient has a history of angina, treat as an anginal episode first. If the patient has no history of angina, treat the situation as if the pain is consistent with a myocardial infarction unless other causes are evident.

Treatment of angina in dental office

If acute myocardial infarction is suspected, position the patient comfortably, assess vitals, activate EMS immediately, administer oxygen, administer nitroglycerin unless systolic pressure is below 100 millimeters of mercury. If the patient is suffering from angina, the nitroglycerin should alleviate the pain within two to four minutes. Another dose of nitroglycerin may be given 5 minutes later and another 5 minutes after that. Only three total doses should be given. If the pain persists, a MI (myocardial infarction) is possible.

Myocardial infarction response

Have you been told to take antibiotics prior to dental treatment? Do you know what type of disorder/defect you have?

Congenital Heart Lesions

Certain congenital heart conditions, including the following, may require premedication: congenital heart defect repaired with prosthetic material.

Premedication for congenital heart conditions

What kind of heart trouble or disease?

Heart problems assessment

Bp at every visit. When did your heart attack occur? Do not treat in the first 6 months following MI. How is your health now? Can you walk up a flight of stairs without stopping to rest? Are you taking any medications? Anticoagulants?

Heart attack questions

Bp at every visit. Do you need several pillows to sleep? Can you tolerate being put in a supine position? Can you walk up a flight of stairs without stopping to rest?

Heart failure assessment

Have you been told that it is the result of a congenital heart disorder/defect?

Heart murmur inquiry

ictal

The middle (________) stage of a seizure is called the _______ phase.