EMERGENCIES IN DENTISTRY

Medical and dental emergencies and complications in dental practice and its management:

 

An emergency is a medical condition that demands immediate attention and successful management. 

These are the life-threatening situations of which every practitioner must be aware of so that needless morbidity can be avoided.

A survey of 4000 dental surgeons conducted by Fast and others revealed an incidence of 7.5% emergencies per dental surgeon over a 10-year period. 

Basic principles of management of medical emergencies:

The golden rule in managing any emergency is rendering basic life support (BLS) measures and cardiopulmonary resuscitation (CPR). 

This is done by following the basic principles: Position (P), Airway (A), Breathing (B), Circulation (C), and Definitive therapy (D),.

The primary positions to manage an emergency are supine position, Trendelenburg position, and semi-erect position.  

Maintaining a patent and functioning airway is the first priority in managing an emergency. This is achieved usually by the head tilt-chin lift manoeuvre. 

If clear airway is still not achieved, then invasive procedures like direct laryngoscopy and cricothyrotomy can be followed. 

The next priority is to check for the presence of adequate breathing which is assessed by the look-feel and listen technique^. 

If spontaneous breathing is not evident then rescue breathing should be accomplished immediately either by the mouth-to-mouth technique or the bag-valve-mask technique. 

After establishing a patent airway and breathing, circulation is assessed. The most rapid and reliable method is by palpating the carotid pulse at the region of the sternocleidomastoid muscle. 

If pulse is absent, then CPR is initiated immediately. Once airway, breathing, and circulation is maintained, definitive treatment is begun if the emergency is acute and cause is clear to the dental specialist. 

Definitive therapy involves administration of drug when indicated and contacting for emergency care.


The medical and dental emergencies that are commonly encountered in dental practice involve syncope, airway obstruction, anaphylaxis, local anesthetic toxicity, asthmatic attack, chest pain, hemorrhage, and seizure. Myocardial infarction and cardiac arrest are extremely rare. Analysis of history and patient counseling and motivation also play a role in minimizing the emergencies.

Syncope:

 




Syncope is caused due to inadequate cerebral perfusion. Causes of sudden loss of consciousness and collapse include hypotension, adrenal crisis, anaphylaxis, cardiac arrest, diabetic collapse, hypoglycemia, epileptic seizure, fainting, or stroke. 


The early manifestations include nausea, warmth, perspiration, baseline blood pressure, and tachycardia. 


Late manifestations include hypotension, bradycardia, pupillary dilation, peripheral coldness, and visual disturbance. 


Most of the syncopal attacks can be prevented by ensuring that the patient has had their meal before treatment in case of systemic diseases like diabetes and also making the patient lie in the supine position before administering local anesthetics.




Management: 


The patient should be in the supine position 


Recovery is almost instantaneous if the patient has simply fainted. 


Then maintain airway, check pulse (if absent, indicates cardiac arrest), and start CPR immediately. 


If pulse is palpable and the patient has not completely lost consciousness, 


Four sugar lumps may be given orally or intravenous 20 ml of 20-50% sterile glucose. 


A hypoglycemic patient will improve with this regimen. But if there is still no improvement medical assistance should be summoned. 


Meantime, hydrocortisone sodium succinate 200 mg IV should be given.

Airway obstruction:

Airway obstruction is usually caused due to accidental slippage, aspiration of foreign objects, or laryngeal spasm. 


Patient manifests with inability to speak, grasps the throat (universal sign), coughs, inability to exchange air (in spite of respiratory movements), cyanosis, and loss of consciousness. 


These might eventually lead to cardiac arrest finally.


Management: 


Main priority is to clear the airway, but the method differs depending upon whether the patient is conscious or unconscious.

If the patient is conscious, then he/she must be made to sit straight, support chest with one hand, and deliver five sharp back blows between the shoulder blades with the heel of the other hand. 


But if the patient is choking, an attempt is made to expel the object with upward thrusts using Heimlich thrust(see Figure).


It acts as artificial cough that produces a rapid increase in intra-thoracic pressure thus helping to expel the foreign body out.


Anaphylaxis:

It is a hypersensitive state that results from exposure to an allergen. 


The most common allergen in a dental setup is latex^.. 


Manifestations vary from a mild form where the patient presents with erythematous rash, cyanosis, nausea, vomiting, tachycardia, utricaria, or angiodema to a severe form which leads to airway obstruction or inadequate blood pressure and blood flow to the brain which is a life-threatening situation. 


Management involves lying the patient in the supine position with legs raised. administer oxygen, and the drug of choice being 0.5 ml of 1:1000 adrenaline IM or SC.




Local anesthetic toxicity:

Local anesthetics are the most commonly used drugs in dentistry. 


Toxicity is usually either due to the local anesthetic itself or the vasoconstrictor which can be due to rapid infusion or failure to aspirate before injection. 


Generally, the reactions are self limiting. 


Toxicity presents with talkativeness, slurred speech, anxiety, confusion, drowsiness, or even seizure and cardiac arrhythmias in extreme cases.


Management: 


Sessate the administration of injection and monitor vital signs. Administer oxygen and in adverse cases administration of diazepam 5 mg slowly is advised^.

Asthmatic attack:

Anxiety, infection, exposure to an allergen or drugs can precipitate an asthmic attack. 


The goal of management during an acute asthmatic episode on a dental chair should be to relieve the bronchospasm associated with the attack.


Patient presents with thickness or heaviness in the chest, difficulty in breathing, spasmodic and unproductive cough, expiratory wheeze, and anxious behavior. 


Hence, the patient should primarily be relieved of irritants and all articles should be removed from oral cavity.


Drug of choice is 2 puffs of albuterol. 


If no improvement is seen in 15 seconds then administer 1:1000 adrenaline 0.5 ml SC/IM and if still no response is observed in 2-3 min then salbutamol slow IV injection is advised.

Chest pain:

Factors that precipitate chest pain include angina, acute myocardial infarction, gastrointestinal reflux disease, anxiety, costochondritis and paroxysmal supraventricular tachycardia.


Patients generally present with tightness, fullness, constriction, or heavy weight on the chest. 


Angina pectoris and acute myocardial infarction (AMI) are the two commonly occurring cardiac problems in a conscious patient. 


Patient's history is of prime concern here. 


If this is the first time patient has ever experienced a chest pain, then dental specialist should treat him or her as if it were an acute myocardial infarction and have emergency medical service transfer immediately. If not then it is an angina pectoris situation.


Quality of pain can also indicate whether the patient is having an angina or acute myocardial infarction. 


In angina pectoris pain is significant but not severe whereas an acute myocardial infarction pain generally radiates to left side of the body-left shoulder, left mandible, left arm.

Management: 


For angina pectoris, drug of choice is a nitrate, commonly nitroglycerine, sublingual tablet, translingual or transmucosal spray. 


Management of a patient with suspected acute myocardial infarction involves administration of morphine, oxygen, nitroglycerine, and aspirin (MONA) in addition to emergency medical service. 


If morphine is unavailable, the specialist can also substitute nitrous oxide/oxygen in a 50:50 concentration.

Haemorrhage:

Haemorrhagic disorders, though uncommon, should always be considered, as dental specialists deal with blood routinely and there are instances when significant bleeding could lead into an emergency. 





Emergency management begins by gently cleaning the mouth and locating the source of bleeding and the application of cold compress, pressure packs, or styptics. 



Suture the area under L.A when necessary. 


Tranexamic acid -500 mg in 5 ml by slow IV injection is the drug of choice.

Seizures:

Patients who convulse in dental office generally have a seizure history and are often characterized as having epilepsy.


Management: If the patients experiencing seizure is unconscious, they should primarily be placed in the supine position and the head tilt-chin lift manoeuvre is performed. 


Dental specialist should remove all instruments from patient's mouth and protect the patient. Clear airway, loosen clothing and help patient breath adequately.


If seizure continues for long, then the condition is known as status epilepticus. 


This is a life-threatening emergency and is best managed with I.V. diazepam 5 mg IV/IM or by maintaining BLS till patient is shifted to emergency medical care.

IN CONCLUSION:

Emergencies cannot be totally prevented but can be managed appropriately with thorough knowledge of the signs, symptoms, and accurate treatment of the emergencies. 

Accomplishing this depends on the combined effort of the dental specialist, staff, and immediate availability of the critical drugs and equipments for the procedure. 

However, no drug can replace an efficiently trained health care professional in managing an emergency but an emergency drug kit and equipment does play an integral role in the course and outcome of management of emergencies and complications in interdisciplinary dental practice.


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