Category Archives: Prevention and Management of Medical Emergencies

Altered Consciousness

Altered Consciousness

An alteration in the level of consciousness of a patient may result from a large variety of medical problems, The altered state can range from lightheadedness to a complete loss of consciousness. Without attempting to

BOX 2-10

Manifestations of Patient Preparing to Vomit

Manifestations of Patient Preparing to Vomit

Manifestations of Patient Preparing to Vomit

include all possible causes of altered consciousness, a discussion is presented of commonly occurring conditions that may lead to an acutely altered state of consciousness while patients are undergoing oral surgical procedures.

Vasovagal syncope. The most common cause of a . transient loss of consciousness in the dental office is vasovagal syncope. This generally occurs because of a series of cardiovascular events triggered by the emotional stress brought on by the anticipation of or delivery of dental
care. The initial event in a vasovagal syncopal episode Is the stress-induced release of increased amounts of catecholamines that cause a decrease in peripheral vascular resistance, tachycardia, and sweating. The patient maycomplain of feeling generalized warmth, nausea, and pal-arterial blood pressure appears, with a corresponding decrease in cerebral blood flow. The patient may then complain of feeling dizzy or weak. Compensatory mechanisms attempt to maintain adequate blood pressure, but they soon fade, leading to vagally mediated bradycardia. Once the blood pressure drops below levels necessary to sustain consciousness, syncope.occurs (Fig. 2-9).

If cerebral ischemia is sufficiently severe, the patient may also develop seizure activity. The syncopal episode and any accompanying seizure usually ends rapidly once. the patient assumes or is placed in a horizontal position with the feet elevated (Fig, 2-1(0). Once consciousness is
regained, the patient may have pallor, nausea, and fatigue for several minutes.

Prevention of vasovagal syncopal reactions involves proper patient preparation. The extremely anxious patient should be treated by using an anxiety reduction protocol and, if necessary, given pretreatment. anxiolytic drugs. Oral surgical care should be provided while the patient is
in a semi supine or fully supine position. Any signs of an impending syncopal episode should be quickly treated by placing the patient in a fully supine position or a position in which the legs are elevated above the level of the heart and by placing a cool moist towel on the forehead. If the
patient is hypoventilatiog and is slow to recover consciousness, a respiratory stimulant such as aromatic ammonia may be useful. If the return of consciousness is delayed for more than a minute, an alternative cause for depressed consciousness other than vasovagal syncope
should be sought. After early recovery from the syncopal episode, the patient should be allowed to recover in the office and then be discharged with an escort. Future office

FIG. 2-8 Management of vomiting patient and of possible aspiretion of qastrlccontents. ----- . .

FIG. 2-8 Management of vomiting patient and of possible aspiretion of qastrlccontents.

visits by the patient will require preoperative sedation, additional anxlety reducing’measures or both.

Orthostatic hvpotension. Another common cause of a transient altered state of consciousness in the dental setting is orthostatic (or postural) hypotension. This problem occurs because of pooling of blood in the
periphery that is not remobilized quickly enough to prevent cerebral ischemia when a patient rapidly assumes an uprighr posture. The patient will therefore feel light headed or become syncopal. Patients with orthostatic hypotensioh who remain conscious will usually complain of palpitations and generalized weakness, Most individuals who are not hypovolemic or have orthostatic hypotension resulting from the pharmacologic effects of drugs such as antihypertensive agents will quickly recover by reassuming the reclined position. Once symptoms disappear the patient can generally sit up (although this should be done slowly) and sit on the edge of the chair for a few moments before standing. Blood pressure can be taken in each position and allowed to return to normal before a more upright posture is assumed (Box 2-11).

In the ambulatory population this is usually encountered in patients receiving the following medications: drugs that produce intravascular depletion, such as diuretics; drugs that produce peripheral vasodilation,
such as most nondiuretic antihypertensives, narcotics, and many, psychiatric drugs; and drugs that prevent the heart rate from increasing reflexly, such as beta-sympathetic antagonist medications (e.g  ropranolol). Patients with a predisposition to postural hypotension
can usually be managed by allowing a much longer period to attain a standing position (l.e., by stop- allow reflex cardiovascular compensation to occur). If the patient was sedated by using long-acting- narcotics, an
antagonist such as naloxone may be necessary .Patients with severe problems with postural hypotension as a result of drug therapy should be referred to their physician for possible alteration of their drug regimen.

Seizure. Idiopathic seizure disorders are exhibited in, many ways, ranging from grandmas seizures, with their frightening display of clonic contortions of the trunk and extremities, to petite mal seizures that may occur with
only episodic ab scenes stare). Although rare, some seizure disorders, such as those secondary to in jury induced brain damage or damage from ethanol abuse, have a known cause. Usually the patient will have had the seizure disorder previously diagnosed ana will be receiving antiseizure medications, such as phenytoin (Dilantin), phenobarbital, or valproic acid. Therefore the dentist should discover through the medical interview the degree of seizure control present to decide if oral surgery
can be safely performed. The patient should be asked

BOX 2-1

Management of Orthostatic Hypotension 

Management of Orthostatic Hypotension

Management of Orthostatic Hypotension

FIG. 2- 10.•Management of vasovagal syncope and its' prodrome

FIG. 2- 10.•Management of vasovagal syncope and its’ prodrome

FIG. 2-9 Pathophysiology and manifestations of vasovagal syncope.

FIG. 2-9 Pathophysiology and manifestations of vasovagal syncope.

to describe what witnesses have said occurs just before, during, and after the patient’s seizures. It is helpful to disover any factors that seem to precipitate the seizure, the patient’s compliance with antiseizure drugs, and the recent frequency of seizure episodes. Patients with seizure
disorders who appear to have good control of their disease, that is, infrequent episodes that are brief in duration and are not easily precipitated by anxiety, are usually able to safely undergo oral surgery in the ambulatory setting. (See Chapter 1 for recommendations.)

The occurrence of a seizure while a patient is undergoing care in the dental office, although usually creating great concern among the office staff, is rarely an emergency that calls for actions other than simply protecting
the patient from self-injury. However, management of the patient during and after a seizure varies, based on the type of seizure that occurs. The patient’s ability to exchange air must be monitored by close observation. If
it appears that the airway is obstructed, measures to reopen it must be taken, for example, by placing the head in moderate extension (chin pulled away from the chest) and moving the mandible away from the pharynx. If the patient vomits or seems to be having problems keeping secretions out of the airway, the patient’s head must be positioned to the side to allow obstructing materials to drain out of the mouth. If possible, high-volume suction should be used to evacuate materials from the pharynx. Brief periods of apnea may occur, which require no treatment other than ensuring a patent airway. However, apnea for more than 30 seconds demands that BLStechniques be initiated. Although frequently described as
being important, the placement of objects between the. teeth in an attempt to prevent tongue biting is hazardous and therefore usually unwarranted.

Continuous or repeated seizures without periods ofrecovery between them are known as status epilepticus. This problem warrants notification of outside emergency assistance because it is the most common type of seizure disorder to cause mortality. Therapy includes instituting measures already described for self-limiting seizures; in addition, administration of a benzodiazepine is indicated. Injectable water-insoluble benzodiazepines such as diazepam must be given IV to allow predi tability of results, which may be difficult in the seizing patient if venous access is not already available. Injectable watersoluble benzodiazepines such as midazolam provide a better alternative, because 1M injection will give a more
rapid response. However, the doctor administering benzodiazepines
for a seizure must be prepared to provide BLS, because patients may experience a period of apnea after receiving a large rapid dose of benzodiazepines.

After seizures have ceased, most patients will be left either somnolent or unconscious. Vital signs should be monitored carefully during this time, and the patient . should not be allowed to leave the office until fully alert
and in the company of an escort. The patient’s primary care physician should be notified to decide if medical evaluation is necessary and if or when ambulatory dental care is advisable-in the future (Fig. 2-11).

Tremors, palpitations, and anxiety usually precede seizures caused by ethanol withdrawal. Therefore the appearance’of these signs in a patient should warrfthe clinician the patient’s condition is instituted. Control is usually obtained by the use of benzodiazepines, which are used’
until the  uintoward effects of abstinence from ethanol cease. Seizures that occur in ethanol-abusing patients are treated in a similar manner to other seizures.

Local anesthetic toxicity. Local. anesthetics, when properly used, are a safe and effective means of providing pain control when performing dentoalveolar surgery. However, as with all medications, toxicity reactions occur if the local anesthetic is given in an amount or in a manner
that produces an excessive serum concentration.

Prevention of a toxicity reaction to local anesthetics generally involves several factors. First, the dose to be used should be the least amount of local anesthetic necessary to produce the intensity and duration of pain control required to successfully complete the planned surgical procedure. The patient’s age, lean body mass, liver function, and history of problems with local anesthetics must be considered when choosing the dose of local anesthesia. The second factor to consider in preventing a local anesthetic
overdose reaction is the manner of. drug administration. The dentist should give the required dose slowly, avoiding intravascular injection, and use vasoconstrictors to slow the entry of local anesthetics into the blood. It
should be remembered that topical use of local anesthetics in wounds or on mucosal surfaces allows rapid entry of local anesthetics into the systemic circulation. The choice of local anesthetic agents is the third important factor to consider in attempting to lessen the risk of a toxicity reaction.
Local anesthetics vary in their lipid solubility, vasodilatory properties, protein binding, and inherent toxicity. Therefore the dentist must be knowledgeable about the various local anesthetics available to allow C!.
rational derision to be made when choosing which drug to administer and in what amounts (Table 2-4).

The clinical manifestations of a local anesthetic overdose vary, depending on the severity of the overdose, how rapidly it occurs, and the duration of the excessive serum concentrations. Signs of a mild toxicity reaction
. may be limited to increased patient confusion, talkativeness, anxiety, and slurring of speech. As the severity of the overdose increases, the patient may display stuttering speech, nystagmus, and generalized tremors. Symptoms such as headache, dizziness, blurred vision, and drowsiness may also occur. The most serious manifestations of local anesthetic toxicity are the appearance of generalized tonic-clonic seizure .activity and cardiac depression leading  to cardiac arrest (Table 2-5).

Mild local anesthetic overdose reactions are managed by monitorlng- vital signs, instructing the patient to hyperventilate moderately with or witbol adwinistering oxygen, and gaining venous access. If signs of anesthetic toxicity do not rapidly disappear, a slow IV..2.5–to 5-mg
dose of diazepam should be given. Medical assistance should also be summoned if signs of toxidty do not rapidly resolve or progressively worsen.

If convulsions occur, patients should be protected from hurting themselves. Basic life-support measures are instituted as needed and venous access gained, if possible, for administration of anticonvulsants. Medical assistance should- be obtained. If venous. access· is available,

FIG. 2-11 Manifestations a~d acute mal1;:~,-ment of seizures

FIG. 2-11 Manifestations and acute management of seizures

TABLE 2-4

Suggested Maximum Dose of Local Anesthetics

Suggested Maximum Dose of Local Anesthetics"

Suggested Maximum Dose of Local Anesthetics”

·Maximum doses are those tor normal healthy.individuals.
“Maximum dose of epinephrine is O.2.mg per appointment.

TABLE 2-5 

Manifestations and Management of Local Anesthetic Toxicity

BLS, Basic Life Support; /'v, intravenous

BLS, Basic Life Support; /’v, intravenous

Table 2-6

Manifestations of Acute Hypoglycemia

Manifestations of Acute Hypoglycemia Mild Severe

Manifestations of Acute Hypoglycemia
Mild Severe

diazepam should be slowly titrated until the sejzure activity stops (5 to 25 mg is the usual effective range). Vital signs should be checked frequently.

Diabetes mellitus. Diabetes .mellitus is a metabolic disease in’ which the patient’s long-term prognosis appears dependent on keeping serum glucose levels close to normal. An untreated insulin-dependent diabetic constantly
runs the risk of developing ketoacidosis-and its,attendant alteration of consciousness, requiring emergency treatment. Although a compliant insulin-taking diabetic may suffer long-term problems because of relatively
high serum glucose levels, the more common emergency situation they encounter is hypoglycemia resulting   a mismatch of insulin dose and  serum glucose. Severe hypoglycemia i$ the emergency situation dentists
are most likely to face when providing oral surgery for  adiabetic patient .

Sfrum glucoseco~centration in-the diabetic patient represents a balance between administered insulin, glucose placed into the serum from various sources, and glucose use. The two primary sources of glucose are dietary
and gluconeogenesis from’ adipose tissue, muscle, and glycogen stores. Physical. activity is the principal means by which serum glucose is lowered. Therefore serum glucose levels can fall because of any or all of the following:
. 1., Increasing administered insulin
2. Decreasing dietary caloric intake
3. Increasing metabolic use of glucose (e.g., exercise,
infection, emotional stress)

Problems with hypoglycemia during dental care usually arise because the patient has acutely decreased caloric intake, an infection, or an increased metabolic rate caused by marked anxiety. If the patient has not compensated for this diminution of available glucose by decreasing the
usual dose of insulin” hypoglycemia results. Although patients taking oral hypoglycemics can also have problems with hypoglycemia, their swings in serum glucose levels are usually less pronounced than those of insulindependent patients with diabetes, so they are much less
likely to quickly become severely hypoglycemic.

Many patients with diabetes are well Informed about their disease and are capable of diagnosing their own hypoglycemia before it becomes severe. The patient may feel hunger, nausea, or lightheadedness or may develop a ,
headache. The dentist may notice th» patient becominglethargic, with decreased spontaneity of conversation and ability to concentrate: As hypoglycemia worsens, the patient may becoine diaphoretic or have tachycardia, piloerection, or increased anxiety and exhibit unusual
behavior, The patient may soon become stuporous or lose consciousness (TabTe2-6).

FIG. 2-12 Management of acute hypoglyc,emia.

FIG. 2-12 Management of acute hypoglyc,emia.

avoided through measures designed to keep serum glucose levels on the high.side of normal or even ‘temporarily above normal. During the health history interview, the dentist should get a clear idea of the degree of control of the patient’s diabetes. If patients do not, regularly check
their own urine or serum glucose, their physician should be contacted to determine whether routine dental cate can be performed safely. Before any planned procedures, measures discussed In Chapter 1 ‘concerning the diabetic patient should be taken.

If a diabetic patient indicates a feeling of low blood sugar or if signs or symptoms of hypoglycemia. appear, the procedure being performed should be stopped and the patient allowed to consume a high-caloric carbohydrate, such as a few packets of sugar, a glass of fruit juice, or other
sugar-contalntng beverages. If the patient fails to rapidly improve, becomes unconscious, or is otherwise unable to take a glucose source by mouth, venous access should be gained and an ampule (SOmL) of 50% glucose (dextrose) in water should be administered IV over 2 to 3 minutes. If ” venous access cannot be established, 1mg of glucagon can be given 1M. If SQ%glucose and glucagon are unavailable, a O.S-mL dose of 1:1000 epinephrine can be administered . SC and repeated every 15 minutes as needed (Fig. 2-12).

A patient who seems to have recovered from a hypoglycemic episode should remain in the office for at least 1 hour, and further symptoms ‘should be treated with oral glucose sources. The patient should be escorted home with instructions on how to avoid a hypoglycemic episode during the next dental appointr.ient.  Thyroid dysfunction. Hyperthyroidism and hypothyroidism are slowly developing disorders that can produce
an altered state of consciousness but rarely cause emergencies. The most common circumstance in which an ambulatory, relatively healthy-appearing’ patient develops an emergency from thyroid dysfunction is when a thyroid storm (crisis) occurs.

Thyroid storm is sudderi, severe exacerbation of hyperthyroidism that mayor may not have been previously .Thyroid storm is sudderi, severe exacerbation of hyperthyr diagnosed. If can be precipitated by infection, surgery, trauma, pregnancy, or any other physiologic or emotional
stress. Patients predisposed to thyroid crisis frequently have signs of hyperthyroidism, such as tremor, tachycardia, weight loss, hypertension, irritability, intolerance to heat, and exophthalmos; they may have eyen received therapy for the thyroid disorder.

Patients with known, hyperthyroidism should have their primary care physician consulted before any oral surgical procedur.e. A determination of the adequacy of control of excessive thyroid hormone production should be obtained from the patient’s physician, and, if necessary,
the patient should receive antithyroid drugs and iodide treatment preoperatively. If clearance for ambulatory surgery is given, the patient should be managed as shown in the outline in Chapter 1.

The first sign of a developing thyroid storm is an ‘elevation of temperature and heart rate. Most of the usual signs and symptoms of untreated hyperthyroidism occur in an exaggerated form” The patient becomes irritable, delirious, or even ‘comatose. Hypotension, vomitirig, and
diarrhea also occur.

Treatment of thyrotoxic crisis begins with terminatiori of any procedure and notification of those outside the office able to give emergency assistance. Venous access should be attained, crystalloid solution started at a moderate rate, and the patient kept as calm as possible. Attempts may be taken to cool the patient until he or she can be transported to a hospital, where antithyroid and sympathetic .blocklng drugs can be administered safely Box 2-12).

Adrenal insufficiency. Primary adrenocortical insufficiency (Addison’s disease) or other medical conditions in which the adrenal cortex has been destroyed are rare. However, adrenal insufficiency secondary to exogenous corticosteroid administration is relatively common because of the multitude of clinical conditions for which therapeutic corticosteroids are given, Patients with adrenal insufficiency are frequently not informed concerning their potential need for supplemental medication, and those with secondary adrenal ‘insufficiency may fail to inform the’ dentist that they are taking corticosteroids. This is not a problem, provided the patient is not physiologically or emotionally stressed.

However, should the patient be stressed, adrenal suppression that results from exogenous corticosteroids may prevent the normal telease of increased amounts of endogenous glucocorticoids needed to help the body
meet the elevated metabolic demands. Patients at risk for acute adrenal insufficiency as a result of adrenal suppression are generally those who take at least 20 mg of cortisol (or its equivalent) daily for at least 2 weeks any time

BOX 2-12

Manifestations of Acute Management of Thyroid Storm

Manifestations
Hyperpyrexia (i.e., fever)
Tachycardia
Nervousness and agitation
Tremor -.
Weakness
Palpitations
Cardiac dysrhythmias
Nausea and vomiting
Abdominal pains
Partial or complete loss of consciousness
Management
Terminate all dental treatment
Have someone summon medical assistance
Administer oxygen
Monitor all vital signs
Initiate BlS if necessary _ _
Start IVline with drip’ of crystalloid solution (150 ml/hr)
-Transport patient to emergency care facility

BLS, Basic Life Support; JII, intravenous.

TABLE 2-7

Equivalency of Commonly Used Glucocorticosteroids

Equivalency of Commonly Used Glucocorticosteroids

Equivalency of Commonly Used Glucocorticosteroids

during the year preceding the planned major oral surgical procedure (Table 2-7). However, in most straightforward oral surgical procedures done under local anesthesia or nitrous oxide-and local anesthesia, administration.of supplemental corticosteroids is unnecessary, When significant adrenal suppression is suspected, the steps discussed
in Chapter 1 should be followed.

Early clinical manifestations of acute adrenal insufficiency crisis include mental confusion, nausea, fatigue, and muscle weakness. As the condition worsens, the patient develops more severe mental confusion; pain in
the back, abdomen, and legs; vomiting; and hypotension. Without treatment the patient will eventually begin to drift in and out of consciousness, with coma harkening the preterminal stage (Box 2-13) .

Management of an adrenal crisis begins by stopping all dental treatment and taking vital signs. If the patient is found to be hypotensive, they must be immediately placed in a head-down, legs elevated position. Medical
assistance should be summoned. Oxygen should be administered and venous access gained. A 100-mg dose of hydrocortisone sodium succinate should be given IV (or 1M, if necessary). IV fluids are rapidly administered until hypotension improves. Vital signs should be measured
frequently while therapeutic measures are being taken. Should the patient lose consciousness, the need for initiation of basic life-support measures should be evaluated (Box 2-14).

Cerebrovascular compromise. Alterations in cerebral blood flow can be compromised in three prindpal ways: (1) -embolization of particulate matter from a distant site, (2) formation of a thrombus in a cerebral vessel; or (3) rupture of a vessel. Material that embolizes to the brain comes most frequently from thrombi in the left side of the heart, from the carotid artery, or from bacterial vegetations on infected heart surfaces. Cerebrovascular thrombi generally form in areas of atherosclerotic
changes. Finally, vascular rupture can occur because of rare congenital defects in the vessel, that is, berry aneurysms.

 

 

 

 

 

 

 

 

Respiratory Difficulty

Respiratory Difficulty

Many patients are predisposed to respiratory problems in the dental setting; these patients include patients with asthma or chronic obstructive pulmonary disease (CO PO), extremely anxious patients, patients who are. atopic, and those in whom a noninhalation sedative technique using respiratory depressant drugs is to be used. Special precautions should be taken to help prevent the occurrence of emergencies. If these patients are not treated promptly, • the situation may become life threatening.
Asthma. Patients with a history of asthma can be a particular challenge to safely manage if emotional stress or many pharmacologic agents easily. trigger their respiratory problems. Most patients with asthma are aware of
the symptoms that signal the onset of bronchospasm. Patients will complain of shortness o( breath and want tosit erect. Wheezing is usually audible; tachypnea and tachycardia begin,and patients start using their accessory muscles of respiration. As bronchospasm progresses,
patients may become hypoxic and cyanotic, with eventual loss of consciousness (Box 2-6).
Management should start with placing patients in an erect or semierect position. Patients should then administer brortchodilators, using their own inhalers or one provided from the office emergency supply. The inhaler may contain epinephrine, isoproterenol, metaproterenol, or albuterol. Repeated doses should be administered caused

BOX 2-6

Manifestations of an Acute Asthmatic Episode

Mild to Moderate
• Wheezing (audible with or without stethoscope)
• Dyspnea (i.e., labored breathing)
• Tachycardia
• Coughing
• Anxiety
Severe
• Intense dyspnea, with flaring of nostrils and use of
accessory muscles of respiration
• Cyanosis of mucous membranes and nail beds
• Minimal breath sounds on auscultation
• Flushing of face
• Extreme anxiety
• Mental confusion
• Perspiration

FIG. 2-4 Manaqernent of acute asthmatic episode occurrin dulln dental surgery

FIG. 2-4 Manaqernent of acute asthmatic episode occurrin dulln dental surgery

Hyperventilation. The most frequent cause of respiratory difficulty in the dental setting is anxiety that is expressed as hyperventilation, which is usually seen in patients in their teens, 20s, and 30s, and can frequently
be prevented through anxiety control. Dentists should be attuned to the signs of patient apprehension and, through the health interview, should encourage patients to express their concerns. Patients with extreme anxiety should be managed with an anxiety reduction protocol. In addition, pharmacologic anxiolysis may be necessary. The first manifestation of hyperventilation syndrome is frequently a complaint of an inability to get enough air. They breathe very rapidly (tachypnea) and become agitated. The rapid ventilation increases elimination of CO2
through the lungs  The patient rapidly becomes alkalotic; may complain of becoming lightheaded and of having a tingling sensation in the fingers, toes, and perioral region; and may even develop muscle twitches or convulsions.
Eventually loss of consciousness occurs (Box 2-7).

Management of a hyperventilating patient involves terminating the surgical procedure, positioning the patrent in a semierect position, and providing reassurance.If symptoms of alkalosis occur, the patient should be forced
to breathe into and out of a small bag (Fig. 2-5). Oxygenenriched air is not indicated. If hyperventilation continues, the clinician may have to administer a sedative such as rnidazolam, DY giving 2 to 4 mg 1Mor by IV titration of the drug until hyperventilation ceases or the patient is
sedated. Once hyperventilation stops, the patient should be rescheduled, with plans to use preoperative or intraoperative sedation (or ‘both) in future visits (Box 2-8).

with. well-compensated COPD can have difficulty during oral surgery. Many of these patients depend on maintaining an upright posture to breathe adequately. In addition, they become accustomed to having high arterial .
CO2 levels and use a low level of blood oxygen as the primary stimulus to drive respirations. Many of these patients experience difficulty if placed in an almost supine position or if placed on high-flow nasal oxygen. Patients with COPD often ·rely on their accessory muscles of respiration to breathe. Lying supine interferes with the use of these accessory muscles; therefore patients will usually ask to sit up before problems resulting from positioning occur. Excessive lung secretions that are more difficult
to clear when supine also accompany COPD.

If .excessive oxygen is administered to a patient susceptible
to COPD, the respiratory rate will fall, which pro-

BOX 2-7

Manifestations of Hyperventilation Syndrome

 

FIG. 2-5 Bag placed over nose and mouth to force rebreathing of CO2-enriched air; reversing tendency for alkalosis caused by hyperventilation. In this case a plastic headrest cover is being usee

FIG. 2-5 Bag placed over nose and mouth to force rebreathing of
CO2-enriched air; reversing tendency for alkalosis caused by hyperventilation.
In this case a plastic headrest cover is being use

anifestations of Hyperventilation Syndrome

Manifestations of Hyperventilation Syndrome

duces cyanosis, and apnea may eventually occur. The treatment for such a problem is to discontinue oxygen administration before the patient becomes apneic. The respiratory rate should soon improve. If apnea occurs and the patient loses consciousness, artificial ventilation must
be initiated ‘and emergency assistance summoned.

Foreign-hody aspiration. Aspiration of foreign bodies into the airway is always a potential problem during oral surgical and other dental procedures. This is especially true if the .patient is positioned supine or semierect in the chair or is sufficiently sedated to dull the gag reflex. Objects that fall into the hypopharynx are frequently swallowed and usually pass harmlessly through the gastrointestinal tract. Even if the clinician’ feels’ confident the material was swallowed, chest and
abdomina.l radiographs should be obtained to eliminate the possibility of asymptomatic aspiration into the respiratory tract. Occasionally the foreign object is aspirated into the larynx, where, in the lightly sedated or
nonsedated patient, violent coughing will ensue that may expel the aspirated material. The patient can usually still talk and breathe. However, larger objects that are aspirated may obstruct the airway and become lodged in such a manner that coughing is ineffective because the
‘lungs cannot be filled with air before the attempted cough. Inthis situation the patient usually cannot produce any vocalizations and becomes extremely anxious. Cyanosis soon appears, followed by loss of consciousness (Box 2-9).

The manner in which aspirated foreign bodies are ma. ;;ed depends primarily on the degree of airway obstruction. Patients with an intact ga reflex and a partially obstructed airway should be allo ed to attempt to
expel the foreign bodY by coughing. If the material will not come up, the patient should be given supplemental oxygen arid transported to an emergency facility to allow laryngoscopy or bronchoscopy to be performed. The completely obstructed but awake patient should have abdominal thrusts ·(Fig. 2-6, A) or Heimlich maneuvers
(Fig. 2-6, B) performed until successful or consciousness is lost. If a patient has a dimiriished gag reflex as a result of

BOX 2″:8
Management of Hyperventilation Syndrome

1. Terminate all dental treatment and remove foreign
bodies from mouth.
2. Position patient in chair in almost fully upright
positttm.
3. Attempt to verbally calm patient.
4. Have patient breathe CO2-enriched air, such as in
and out of a small bag.
5. If symptoms persist or.~orsen, administer diazepam.
10 mg 1Mor titrate slowly IVuntil anxiety isrelieved,
or administer midazolam 5 mg 1Mor titrate slowly IV
uritil anxiety is relieved.
6. Monitor vital signs.
7.. Perform all.further dental surgery using anxietyreducing
measures.
1M, Intramuscular; III, intravenous .

Respiratory Difficulty

Respiratory Difficulty

Respiratory Difficulty

Respiratory Difficulty

He. 2-6 A, t\ lethod of f1crfc,~;nmg abdominal thrusts for an unconscious patient with foreign body obstructing airway. Chair is first placed in recumbent position. The heel of the dentist’s right palm is placed on the abdomen just below the xiphoid process, with the elbow Kept locked and the left hand placed over the right for further delivery of force. Arms are quickly thrust into ‘the patient’s abdomen, directing force down and superiorly. 8, Proper positioning  for Heimlich maneuver is shown. Rescuerapproaches the patient from behind and positions hands on the patient’s abdomen, just below the rib cage. Rescuer’shands are then quickly pulled into the abdominal area, attempting to have any residual air in the lungs dislodge  the obstruction from airway.

BOX 2-9

Acute Manifestations of Aspiration into the Lower Respiratory Tract

Large Foreign Body Gastric Contents • Coughing • Coughing • Choking sensation • Stridcrousbreathlnq • Stridorous breathing • Wheezing or rales
(l.e., crowing sounds) (i.e., cracking sound) • Severe dyspnea on chest auscultation
• Feeling of something • Tachycardia
caught.in throat • Hypotension .
• Inability to breathe • Dyspnea • Cyanosis • Cyanosis
• Loss of consciousness

sedation or has a completely obstructed airway and loses consciousness, abdominal thrusts should be performed with the patient in a supine position. After each volley of thrusts, the patient should be quickly turned onto the side and the clinician should finger sweep the mouth to remove any Object that may have been forced out. Ifthe patient is not exchanging air, BLS should be started. If air cannot be blown into the lungs., additional abdominal thrusts should be attempted, followed by oral finger sweeps and BLS. Dentists trained-in laryngoscopy can look into the larynx and use Magill forceps to try to remove any foreign material. If several attempts to relieve the obstruction fail, an emergency cricothyrotomy may be necessary (Fig. 2-7) .

contents into the lower respiratory tract presents another situation that frequently leads to serious respiratory difficulties. The particulate matter in gastric contents causes physical obstruction of pulmonary airways, but it is usually the high acidity of gastric material that produces more serious problems. The low pH of gastric juice quickly necrotizes the pulmonary tissue it contacts, and a respiratory distress syndrome soon follows, with transudation of fluid into pulmonary alveoli and a loss of functioning lung tissue. The patient with an intact gag reflex rarely aspirates gastric contents during vomiting. Rather it is the patient with a diminished gag reflex
caused by sedatiori, unconsciousness, or topical anesthesia in the oropharynx who is at greatest risk ‘for gastric aspiration. The sedated or unconscious patient who aspirates a signiflcant amount of gastric material will first show signs of respiratory difficulty, ‘such as tachypnea
and wheezing. Tachycardia and hypotension may soon occur and, as ventilatory capability worsens, cyanosis appears. Eventually respiratory failure occurs that is refractory to BLS and requires both intubation and the
delivery of high concentrations of oxygen.

Prevention of gastric aspiration involves instruction to patients to avoid eating or drinking for I) hours before any oral surgery appointment during which they are to be moderately or deeply sedated.

FIG. 2-7 Management of respiratorytract foreign-body a~pirationin patient undergoing dental surgery

FIG. 2-7 Management of respiratorytract foreign-body a~pirationin patient undergoing dental surgery

A deeply sedated or unconscious patient who begins to vomit should be immediately placed into a head-down, feet-raised position and turned onto the right side to encourage oral drainage of vomitus, Box 2-10 lists several
symptoms exhibited by patients preparing to vomi t. High-volume suction should be used to assist removal of vomitus from the oral cavity, If the clinician suspects that gastric material may have entered the lower respiratorv tract, a call should be placed for emergency assistance.
The patient should be placed on supplemental oxygen and vital signs monitored, If possible, the dentist should gain venous access (i.e., start an IV) and be prepared to administer crystalloid solution (e.g. normal saline or OsW) to help treat a falling blood pressure and allow emergency technicians to administer IV bronchodilators if necessary. Immediate transportation to an emergency facility is mandatory (Fig, 2-8).

 

 

Chest Discomfort

Chest Discomfort

The appearance of chest discomfort in the perioperative period in a patient who may haveischemic heart disease calls for rapid identification of the cause so that approve.

‘Cricothyrotomy is the surgical creation of an opening into the cricothyroid membrane just below the. thyroid cartilage to create a path for ventilation that bypasses the larynx

BOX 2-4

Clinical Characteristics of Chest Pain Caused by Myocardial Ischemia or Infarction

Discomfort (Pain) Described by Patients as Being:
1. Squeezing, bursting, pressing, burning, choking, or
crushing in character (not typically sharp or stabbing
in quality)
2. Substernally located, with variable radiation to left
shoulder, arm, or left side (or a combination of these
areas) of neck and mandible
3. Frequently associated at the onset with exertion,
heavy meal, anxiety, or upon assuming horizortal
posture .
4. Relieved by vasodilators, such as nitroglycerin, or
rest (in the case of angina)
5. Accompanied by dyspnea, nausea, weakness, palpitations,
perspiration, or a feeling of impending
doom (or a combination of these symptoms)

priate measures can be taken (Box 2-4). Discomfort from cardiac ischemia is frequently described as a squeezing· sensation, with a feeling of heaviness on the chest (Box 2-5). It usually begins in a retrosternallocation, radiating
to the left shoulder and arm. Patients with documented heart disease who have had such discomfort in the past will usually be able to confirm that the discomfort is cardiac in origin. For patients who are unable to remember
such a sensation in the past or who have been assured by their physician that such discomfort does not represent heart disease, further ipformation is useful before assuming a cardiac origin of the symptom. The patient should be asked to describe the exact location of the discomfort and any radiation, how the discomfort is changing with time, and if postural position affects the discomfort. Pain resulting from gastric reflux into the esophagus because of chair position should improve when the patient sits up and is .given an antacid. Discomfort caused by costechondritis
or pulmonary conditions should vary with res” pirations or be stimulated by pressure on the thorax. The only other common condition that can occur with chest discomfort is anxiety. which may be difficult to. differentiate from cardiagenic problems without the use of menitaring
devices not commonly present in the dental office.

If chest discomfort is suspected to be caused by myocardial ischemia or if that possibility cannot be ruled out, measures should be instituted that decrease myocardial work and increase myocardial ox}’gen supply. All dental care must be stopped, even if the surgery is only partially
finished. The patient should be reassured that everything is under control while vital signs are being obtained, oxygen administration is stinted, and nitroglycerin is administered sublingually or by oral spray. The nitroglycerin dose should be 0.4 mg dissolved sublingually and repeated
(if necessary) every 5 minutes as long as systolic blood pressure is at least 90 mm Hg, up to a maximum of 3 .doses, If vital signs remain normal, the chest discomfort is relieved, and the Jl11011nt of nitroglycerin that was

Box 2-5

Differential Diagnosis of Acute-Onset Chest Pain

Common Causes
Cardiovascular system; Angina pectoris, M}
Gastrointestinal tract: Dyspepsia (i.e., heartburn), hiatal
hernia, reflux esophagitis, gastric ulcers
Musculoskeletal system: lntercostal muscle spasm, rib or
chest muscle contusions
~sychologic: Hyperventilation
Uncommon Causes
Cardiovascular system: Pericarditis, dissecting aortic
aneurysm
Respiratory system: Pulmonary embolism, pleuritis, tracheobronchitis,
mediastinitis, pneumothorax –
Gastrointestinal tract: Esophageal rupture, achalasia
Musculoskeletal system: Osteochondritis, chondrosternitis
.Psychologic: Psychogenic chest pain (i.e., imagined. chest pain).

required to relieve the discomfort was not more than normally necessary for that patient, they should be discharged with plans for future surgery to be done in an oral and maxillofacial surgery office or in a hospital after
conferring with their physician (Fig. 2-3). Some circumstances do require transport to an emergency facility. If the pulse is irregular, rapid, or weak, or the blood pressure is found to be below baseline, outside emergency help’ should be summoned while the patient is placed in an almost supine position and oxygen and nitroglycerin therapy.are started. Venous access should be initiated and a slow DsW drip begun, if possible, for use
by emergency personnel. Another serious situation requiring transfer to a hospital is a case in. which the patient’s discomfort is not relieved after 20 minutes of appropriate therapy. In this case it should be presumed
that a myocardial infarction (Ml) is in progress. Such a patient is especially prone to the appearance of serious cardiac dysrhythmias. or cardiac arrest; therefore vital _signs should be monitored frequently, and BLSshould be
instituted if indicated. Morphine sulfate (4 to 6 mg) may be administered 1M or SC to help relieve the discomfort and reduce anxiety. Morphine also provides a beneficial

FIG. 2·3 Management of patient having chest discomfort while undergoing dent!!.,surg!!L. __

FIG. 2·3 Management of patient having chest discomfort while undergoing dental surgery

effect for patients who are developing pulmonary edema (see Fig. 2-3). Transfer to a hospital should be expedited .• because thrombolytic agents and/or an angioplasty procedure may be able to preserve some or all of the ischemic myocardium.

 

Hypersensitivity Reactions

Hypersensitivity Reactions

Several of the drugs administered to patients undergoin  oral surgery can act as antigenic stimuli, provoking allergic reactions. Of the four basic types of hypersensitivity reactions, only type I (immediate hypersensitivity) can
cause an acute; life-threatening condition. Type I aller ic reactions arc mediated primarily by immunoglobulin E (IgE) antibodies. As with all allergies, initiation of a type I response requires exposure to. an .antigen previously seen by the immune system-The reexposure to the anti.

TABLE 2-2

Emergency Drugs for the Dental Office

Principle of surgery

Principle of surgery

gen triggers a cascade of events that then are exhibited locally, systemically, or both in varying degrees of severity. Table 2-3 details the manifestations of type I hypersensitivity reactions and their management.
The least severe manifestation of type I hypcrsvnsitivitv is dermatologic. Skin or mucosal reactions include localized areas of pruritus (itching), erythema, urticaria (wheals (on the  sisting of slightly elevated areas of epithelial tissuethat are erythematous and indurated), and angioedema (large areas of swollen tissue generally with little erythema or indura-
-tion). Although skin and mucosal reactions are not in themselves dangerous, they mJY he the first -indication of more serious allergic manifestations that will soon follow. Skin Ie,:;ions usually take anywhere from minutes tohours to appear; however, those appcaringrapldly after administration of an antigenic drug are the most foreboding.
Allergic reactions affecting the respiratory tract are more serious and require more aggressive intervention, The involvement of small airways occurs with wL”~ziiig, as constriction of bronchial smooth muscle (bronchospasm) and airway mucosal inflammation occurs. The patient will
complain of dyspnea and may eventually become cyanotic. Involvement of tire larger airways usually first OCCL:r, at the narrowest portion of those air passages-the vocal cords in the larynx. Angioedema’ of the vocalcords causes ‘partial or total airway obstruction. The patient is usuallyunable to speak and produces high-pitched crowing sounds (stridor) as air passes through constricted cords. As the edema worsens, total airway obstruction ewntually occurs, which is an immediate threat to life.

Generalized anaphylaxis is the most dramatic hypersensitivity reaction, usually occurring within seconds or minutes after the parenteral ‘administration of the antigenic medication; a more delayed onset occurs after oral or topical drug’ administration.’ A variety of signs and symptoms of anaphylaxis exist, but the most important with respect ‘to early management are those resulting from cardiovascular and respiratory tract disturbances.

An anaphylactic reaction typically begins with a patient complaining of malaise or a feeling of impendingdoom. Skin manifestations soon appear, including flushing, urticaria, and pruritus on the face and trunk. Nausea and
vomiting, abdomin l cramping, and urinary incontinence may occur. Symptoms of resplratory-cmbarrassrnent soon follow, with dyspnea and wheezing. Cyanosis of nail-beds and mucosa will next appear if air exchange becomes insufficient. Finally, total airway obstruction occurs, which
causes the patient to quickly become unconscious.  isordered cardiovascular function initially occurs with tachycardia
and palpitations, Blood pressure, tends to fall because of falling cardiac output ane! peripheral vasodilation, and cardiac dysrhythmias appear, Cardiac output eventually may be compromised to a degree sufficient to
cause luss of consciousness and cardiac arrest. Despite the potentially severe cardiovascular disturbances, the usual cause of death in patients having an anaphylactic reaction. is laryngeal obstruction caused by vocal cord edema.

As with any potential emergency condition, prevention , is the best strategy. During the initial interview and subsequent recall visits, patients should be questioned about drugs to which they have a history of allergy. In addition,dentists should ask patients specifically about medications
they intend to use during the planned oral surgical care. If a patient claims to have an allergy to a particular drug, the clinician should question the patient further concerning the way in which ture allergic reaction is exhibited and what was necessary to manage the problem.  Thepatients
will claim an emergency to local anesthetics. However, before subjecting patients to alternative forms Qf anesthesia, the clinician should try to ensure that an allergy to the local anesthetic does indeed exist, because many patients have been told they had an allergic reaction when in fact they experienced a va50\’ag,11 hypotensive episode or mild palpitations.
If an allergy is truly in question, the patient may require referral to it physician who can perform hyperscnsittvlty testing. After it isdetcrrnincd that a patient does have a drug allergy, the information should he displayed
prominently on the patient’s record in a way to alert care providers but still protect patient confidentiality .

Management of allergic reactions depends all the severity of the signs and symptoms. The initial response to any sign of untoward reaction to a drug being given parenterally should be to cease its administration, If the
allergic reaction is, confined to the skin, or mucosa. an ant ih istantinc should be administered either IV or intramuscularly JI \ 1), Pi phenhydr.un inc hyd roch Imide IBcnadryl) S() Illg or c.hlorphcniraminc maleate (Chlor-Tr irneton) 10 rug are the commonly chosen  ntihistamines. The antihistamine is then continued in all oral form .

TABLE 2-3

Manifestations and Management of Hypersensitivity (Allergic) Reactions 

M.mifestations and Management of Hypersensitivity (Allergic) Reactions

M.mifestations and Management of Hypersensitivity (Allergic) Reactions

 

‘Brand of diphenhydramine.
tBrand of chlorpheniraminc.
*As described in “Immediate Onset” section.
BLS, Basic life Support; 1M, intramuscular; I\~ intravenous: SC, subcutaneous.

(Bcnadryl SO mg or Chlor-Trimeton 8 mg) every 6 to 8-
hours for 24 hours. Immediate, severe urticarial reactions
warrant immediate parenteral (subcutaneous ISCj or IM

•All doses given in t h is chapter arc those recommended for an average adult. Doses will  be for chrkh cn, f;)f older adults, ;l/Jd fur those
with debilitation diseases, The clinician should consult a drug refercnce book for additional information administration of 0.3 mL of a 1:1000 epinephrine solution, followed by an antihistamine. The patient’s vital signs should be frequently monitored for 1 hour; if stable the patient should be referred to a physician or an emergency care facility for further follow-up .

If a patient begins to show signs of lower respiratory tract involvement (i.,. wheezing during an allergic reaction), several actions should be initiated. Outside emergency gency assistance should be summoned. The patient should be placed in a sejnireclined position and oxygen administration
begun ..Epinephrine should be administered either by parenteral injection of 0.3 mL of a 1:1000 solution or with an aerosol inhaler (e.g., Medihaler-Epi, each inhalation of which delivers 0.3 mg), Epinephrine is short acting:
if symptoms recur or continue, the dose can be repeated within 5 minutes. Antihistamines such as diphenhydramine or chlorpheniramine are then given. The patient should be transferred to the nearest emergency facility to allow further management as necessary .

If a patient shows signs of laryngeal obstruction (i.e., stridor), epinephrine (0.3 mL of 1:1000 solution; should be given and oxygen administered. If a patient loses consciousness and appears to be unable to ventilate, an emergency cricothyrotomy or tracheotomy may be required to
bypass the laryngeal obstruction.* A description of the technique of cricothyrotorny or tracheotomy is beyond the scope of this book, but these techniques may be lifesaving in an anaphylactic reaction. Once an airway is reestablished, an antihistamine and further doses of epinephrine
should be given. Vital signs should be monitored, and steps necessary to maintain the patient should be taken until emergency assistance is available.

Patients who show signs of cardiovascular system compromise should be closely monitored for the appearance of hypertension, which may necessitate initiation of BLS if cardiac output falls below the level necessary to maintain viability or if cardiac arrest occurs (see Box 2-3).

 

MEDICAL EMERGENCIES

MEDICAL EMERGENCIES

A brief description of the pathophysiology, clinical manifestations, and acute management of several emergency situations is presented. in the following section. It ha been organized into a combination oispecitic problems such as hypersensitivity reactions, and symptom-oriented problems, such as chest discomfort.

Emergency Supplies and Equipment

Emergency Supplies and Equipment

1he final means of preparing for emergencies is by tonsuring that appropriate emergency drugs and equipment are available in the office. One. basic piece of equipment IS the dental chair that should be capable of all offering the patient to be placed in a flat position or, even better, in a head-down, feet-raised position (Fig. 2-1, A). In addition, the chair must be capable of being lowered close to the floor to allow BLS to be performed properly. Operatories should be large enough to 1I0wa patient to be placed on the floor for BLS performance and provide enough room for the dentist and others to deliver emergency care. If the operatory  is too small to allow the patient to be placed on the floor, specially designed boards are available that can he placed under the patient’s thorax to allow BLS administration in the dental chair.

Prevention and Management of Medical Emergencies

TABLE 2-1

Emergency Supplies for the Dental Office

"For use by dentists with appropriate training or by those (ailed to give medical assistance. AMBU, Air Mask Bag U~it.

“For use by dentists with appropriate training or by those (ailed to
give medical assistance.
AMBU, Air Mask Bag UNIt.

use or for others called’ into the office to assist during an emergency.

Useful drug administration equipment includes syringes and needles, tourniquets, intravenous (IV) solutions, indwelling catheters, and IV tubing (Table 2-1). Although emergency kits containing a variety of drugs are comrnercially available (Fig. 2-2), dentists may prefer to assemble
tj)in the 11 kits. This allows properly educated dentists to choose only those agents they feel are likely to be most useful during an emergency, It also helps the dentist to organize the kit in a manner that is easy to use during emergency situations. If dentists have made arrangements for help
from nearby professional, they may also want to include drugs in their kits that the assisting individuals suggest may be helpful. The drugs and any equipment in the kit must be well labeled and checked frequently for completeness and to ensure that no drugs have gone out of date. Labeling can in dude not only the drug name but also situations in which the .drug is most commonly used. A list of drugs that should be considered for  neclusion in a dental office emergency kit appears in Table 2-2.

One emergency drug that must be available in dental offices is oxygen. Many dentists use oxygen supplied in a portable tank. If properly trained or assisted by a properly trained individual, the dentist needs to provide a
means of delivering the oxygen under positive ‘pressure to the patient. It is important to establish a system to periodically check that a sufficient  supply of oxygen is always

FIG. 2-2 Example of commercially available emergency kit of appropriate size and complexity for dental office.

FIG. 2-2 Example of commercially available emergency kit of
appropriate size and complexity for dental office.

available. Dentists who use a central oxygen system also need to have oxygen available that is portable-for use outside of the operator, such as in the waiting room or during transport to an emergency facility.

Access to Help

Access to Help

The ease of access to other health care providers varies from office to office. It is helpful to seek out individuals with training that would make them useful during a medical emergency. If the dental practice is located near other professional offices, prior arrangements should be made to
obtain assistance in the event of an emergency. Not all physicians are well versed in the management of emergence and dentists must be selective in the physicians they contact for help during an emergency. Oral- axillofacial
surgeons are a good resource, as are most general surgeons and anesthesiologists. Ambulances carrying emergency medical technicians (EMTs) are useful to the dentist facing an emergency situation, and most communities now provide easy telephone ‘access (911) to a rapid-response EMT team. Finally, it is important to identify a nearby hospital or freesranding emergency care facility with well-trained emergency care experts.

Once the dentist has established who can be of assistance in the event of an emergency, the appropriate .phone numbers should be kept readily available. Easily  dentified lists can be placed on each telephone, or numbers can be entered into the memory of an automatic-dial telephone. The numbers should be called periodically to test their accuracy and to ensure that the person to be reached is available to respond.

Office Staff Training

Office Staff Training

The dentist must- ensure that all office personnel are trained to assist in the recognition and management of emergencies. This should include reinforcement by regular emergency drills in the office and by biannual BLS
skills renewal. The office staff should be preassigned specific responsibilities so that in the event of a problem each person knows what will be expected during an emergency.

Continuing Education

Continuing Education

In dental school, clinicians are trained in ways to assess patient risk and manage medical emergencies. However, because (if the rarity of these problems, practitioners should seek continuing education in this area, not only torefresh their Knowledge but also to learn’ new concepts concerning medical evaluation and management of emergencies. An important feature of continuing educa-tion should be to maintain certification in Basic Life Support
(Hl.S) (Box 2-3). Many have recommended that continuing education in medica, emergency management be obtain on an annual  basis  with a  lS’skills update and review obtained biannually Dentists who deliver par enteral sedatives other than nitrous oxide are wise to become certified in Advanced Cardiac Life Support (ACLS), including the use of automated external defibrillator units, and to have the drugs and equipment necessary
for ACLS available.

Prevention and Management of Medical Emergencies

Prevention and Management of Medical Emergencies

BOX 2-3

Basic Life Support

ABCs:
• A-Airway
• B-Breathing
Ili (-Circulation
Airway obtained and maintained by combination of:
1. Extending head at the neck by pushing upward on
the chin with one hand and pushing the forehead
back with other hand
2. Pushing mandible forward by pressure on the
mandibular angles
3. Pulling mandible forward by pulling on anterior
mandible
4. Pulling tongue forward, using suture material or
instrument to grasp anterior tongue
Breathing provided by one of tile [ollowing:
1. Mouth-to-mouth or mouth-to-mask ventilation
2. Resuscitation bag ventilation
Circulation provided by external cardiac compressions

In dental access to other health care providers able to assist during emergencies, and H) equipping the office with supplies necessary to initially care for patients having serious problems (Box 2-2).