Medical emergencies at the dental office.
Plan
- Introduction
- Vital Signs Characteristics
- The different emergency medical situations:
- cardiovascular emergencies
- respiratory emergencies
- metabolic emergencies
- neurological emergencies
- allergic reactions
- Emergency medications
- Emergency equipment
- Conclusion
Introduction: Although not common, medical emergencies are not an exception in the dental office. These incidents are likely to have serious consequences and it is likely that their importance will continue to increase in the future.
Vital Signs Characteristics:
| Vital signs | Normal values |
| Pulse (beats/min) | 60-100 |
| Systolic pressure (mm Hg) | 90-140 |
| Diastolic pressure (mm Hg) | 60-90 |
| Respiratory rate (breaths/min) | 15-20 |
Emergency medical situations
- Cardiovascular emergencies
1.1. Vagal shock (Lipothymia): This condition is one of the most common emergency situations. It is often linked to anxiety, fatigue, fasting, and pain.
It consists of a loss of consciousness preceded by the following clinical signs: – Pallor, dizziness, nausea, sweating. – The essential sign is a weak and poorly perceived pulse accompanied by hypotension.
Action to take:
- Stop treatment;
- Clear the airways;
- Place the patient in the supine position with the legs elevated; – Monitor blood pressure and pulse.
The evolution is often favorable in the absence of treatment. The disorders disappear spontaneously. It is then possible to resume care.
If the condition worsens, consciousness disorders persist and cardiovascular disorders appear. It is necessary to:
- Give an intravenous injection of atropine sulfate (1/4 to 1/2 mg) and continue clinical monitoring;
- Call emergency medical personnel and prepare ventilatory support equipment.
Medical emergencies at the dental office.
1.2. Syncope: It is caused by stress, anxiety and pain, it is a loss of consciousness lasting from a few seconds to a few minutes at most.
Clinical signs:
- It is characterized by a very brief cardio-respiratory arrest with pallor and sudden loss of consciousness;
- Associated signs are hypotension and bradycardia. Management:
- Stop treatment;
- Clear the airways;
- Lay the patient down with his legs raised;
- Monitor vital signs and place cold compresses on the forehead and forearms.
The evolution is favorable if the signs regress within a minute:
- If so, investigate the etiology of the syncope;
- If the evolution is unfavorable, provide oxygenation and external cardiac massage; – Notify emergency medical services.
1.3. Cardiovascular arrest
Circulatory activity disappears. This is a very serious emergency situation.
Clinical signs
- There is disappearance of the carotid pulse, sudden loss of consciousness
- Blood pressure is zero (BP = 0);
- During surgery, blood stops flowing from the surgical wound;
- Respiratory arrest and mydriasis (dilation of the pupils) are often associated. – Mydriasis is a sign of severity indicating brain damage.
Action to take:
- Airway clearance;
- Immediate call for emergency medical services;
- Cardiopulmonary resuscitation of the patient lying down, avoiding tilting the tongue backwards if possible, and otherwise lateral safety position;
- Ensure breathing (mouth-to-mouth ventilation or bag-type mask);
- External cardiac massage;
- Administration of adrenaline intravenously or intratracheally.
Cardiopulmonary resuscitation:
Place the victim on his or her back on a hard surface;
Perform 30 compressions on the lower half of the sternum in adults and 5 in children and infants.
After the compressions, place the patient’s head back, raise the chin and perform 2 effective breaths (the victim’s chest should rise each time you blow) in adults, 1 in children and infants.
The frequency of sternal compressions should be 100 per minute, regardless of age, combined with 8 to 10 effective breaths.
Continue resuscitation efforts and monitor their effectiveness.
Every 5 cycles of 30 compressions and 2 breaths in adults (10 cycles of 5 compressions and 1 breath in children and infants), stop CPR to check for signs of circulation (such as the victim coughing or moving, or starting to breathe again).
This search should not last more than 10 seconds.
Medical emergencies at the dental office.
1.4. Angina pectoris:
It is caused by insufficient blood flow due to coronary ischemia which reduces oxygenation of the heart. Clinical signs:
- Chest pain of sudden onset, radiating to the left shoulder, arm, jaw and face;
- Rhythm disorders; – Blood pressure disorders.
Action to take:
- Call the emergency or cardiology department;
- Lay the patient down;
- Administer oxygen and nitrate derivatives (natispray).
- If the first puff is ineffective, a second and then a third are administered at 5-minute intervals.
- If there is no improvement after administering 3 puffs of nitrates, it could be a myocardial infarction.
1.5. Myocardial infarction:
Heart attack and necrosis of the heart muscle are linked to the mismatch between oxygen supply and needs.
Clinical signs:
- Appearance of pain at rest, in the form of retrosternal chest compression resistant to the administration of nitrate derivatives; – Tachycardia or bradycardia; – Hypertension or hypotension; – Dyspnea.
Action to take:
- Contact emergency medical services;
- The initial treatment is that of angina pectoris;
- If there is no improvement after administration of 3 puffs of nitrates, – Emergency services should be contacted without delay; – Continue oxygenation.
1.6. High blood pressure:
Hypertension is defined as an elevation of systolic blood pressure above 140 mm Hg and diastolic blood pressure above 90 mm Hg. It can be caused by stress and ketamine.
Clinical signs:
- Headaches;
- Unusual bleeding;
- Dyspnea;
- Sweat ;
- Nausea and vomiting; – Tinnitus.
Action to take:
- Stop current treatment;
- Reassure the patient;
- Ensure oxygenation;
- Monitor blood pressure;
- Contact emergency medical services.
1.7. Hypotension:
Hypotension is defined as a systolic blood pressure value below 90 mm Hg. It is favored by hemorrhage, excessive premedication and fatigue. Clinical signs:
- Pallor, dizziness, especially when changing from clinostatism to orthostatism; – Loss of consciousness.
Action to take:
- Stop treatment and ensure hemostasis if necessary;
- Lay the patient down with his legs raised;
- Administer atropine if necessary, if adrenaline fails; – Monitor blood pressure and respiration; – Contact emergency medical services.
- Respiratory emergencies:
2.1. Inhalation of a foreign body:
- A foreign body stuck in the airway obstructs ventilation.
- Obstruction is particularly common in babies and young children.
- A foreign body can partially or completely obstruct the airway.
- Partial obstruction is the most likely situation in a dental office.
- These inhalation accidents must be distinguished from swallowing accidents in which the foreign body passes through the digestive tract. In the latter cases, there is no respiratory discomfort or coughing.
Heimlich maneuver:
The rescuer stands behind the victim against their back, passing their arms under the victim’s arms at the upper part of their abdomen. The victim’s upper body is leaned forward and then the rescuer places their fist on the upper part of the abdomen in the pit of the stomach above the navel and below the sternum. The back of their hand is turned upwards with a horizontal fist. The other hand is placed on top of the first, with the forearms not pressing on the ribs. Pressure is then applied backwards and upwards. The aim of this manoeuvre is to compress the lungs to create a “flush” effect at the trachea.
2.2. Cardiopulmonary arrest
Respiratory arrest may be produced by excessive premedication or anesthetic gas. Clinical signs:
- Respiratory arrest;
- Even if respiratory movements are perceived, inability to inhale; – Appearance of cyanosis and congestion of the face.
Action to take:
- Clear the oral cavity;
- Preventing the tongue from tilting backwards (Guedel or Mayo cannula)
- Ensure oxygenation;
- Call emergency medical services (EMS).
2.3. Asthma attack
An asthma attack is defined by bronchoconstriction of the small distal airways and can be triggered by an allergen, infection or stress.
Clinical signs:
- Wheezing;
- Chest tightness; – Productive or non-productive cough; – Expiratory discomfort.
- If the evolution is unfavorable, cyanosis due to hypoxia appears.
Action to take:
- Stop treatment;
- Administer a bronchodilator of the B2 mimetic type (Ventoline®);
- Ensure oxygenation;
If the asthma attack persists, combine B2 mimetics with corticosteroids;
- If the condition worsens or there is no immediate improvement, contact emergency medical services.
2.4. Metabolic emergencies
2.4.1. Hypoglycemia:
May occur in known diabetic patients and in non-diabetic subjects with prolonged fasting, the onset may be sudden. Clinical signs:
- Sudden irritability;
- Discomfort associated with lethargy; – Feeling of overwhelming hunger; – Nausea.
- Excessive sweating occurs;
- Disturbances of consciousness and neuromuscular tone may be associated. Management:
- Stop treatment;
- Place the patient in the supine position.
- If the patient is conscious, take 4 to 5 pieces of sugar to be chewed slowly;
- If the patient is unconscious or too agitated, direct intravenous injection of 30% glucose serum. This treatment is supplemented by oral sugar intake as soon as the clinical condition improves; – Monitoring of blood sugar;
- If symptoms persist, call emergency medical services.
2.4.2. Hypoglycemic coma
This coma consists of a loss of consciousness associated with intense muscular hypertonia and convulsions.
It occurs mainly in diabetic patients treated with insulin.
Action to take:
- Stop treatment;
- Urgent re-sugar;
- Administration of 30% glucose serum directly intravenously;
- Ensure oxygenation;
- Check blood sugar;
- Contact emergency medical services.
- If blood sugar is below 4, strongly recommend medical monitoring.
2.4.3. Diabetic coma:
It is due to hyperglycemia. Unlike hypoglycemic accidents, its onset is slow.
Clinical signs:
- Headaches, fatigue;
- Abdominal pain, nausea, vomiting;
- Dry and hot skin;
- Rapid pulse, smell of acetone on exhalation.
Without treatment, the coma progresses towards worsening.
Action to take:
- Ensure oxygenation; – Check blood sugar;
- Administer saline solution by infusion and contact emergency services.
2.4.4. Adrenal crisis:
Patient on chronic corticosteroid therapy or who has received high-dose steroids in the last year. Clinical manifestations
- Vascular collapse;
- Altered state of consciousness;
- Fast, pounding pulse;
- Cold and damp extremities;
- Nausea, vomiting;
- Diarrhea;
- Severe abdominal pain.
Action to take:
- Supine position
- Airway clearance
- Oxygen 100%
- Vital signs monitoring
- Hydrocortisone 2ml of 50mg/ml intramuscular or intravenous – Transport to hospital.
- Neurological emergencies
3.1. Epileptic seizure:
Seizures can occur in patients with epilepsy or be triggered by fatigue, alcohol intake or certain medications (local anesthetics).
Clinical signs:
- Sudden onset of involuntary muscle contractions;
- Possible association of ventilatory distress, hypoglycemic discomfort or acute cardio-circulatory failure. Management:
- Stop treatment;
- Protect the patient from trauma;
- Clear the airways; – Ensure oxygenation;
- Inject Valium® (anxiolytic (tranquilizer) from the benzodiazepine family) or Rivotril® (non-barbiturate anticonvulsant from the benzodiazepine family) intramuscularly if convulsions persist beyond 5 minutes and notify emergency medical services.
3.2. Spasmophilia (tetany):
It occurs in patients who are anxious or have a calcium or magnesium deficiency.
Clinical signs:
- facial paresthesia with tingling sensations that may spread;
- In minor forms, spontaneous cramps of the upper and lower limbs
may be associated with facial muscle twitching and hyperventilation;
- In major forms, hyperventilation is intense and contractures are generalized. Consciousness and cardio-circulatory status are not altered.
Action to take:
- Reassure the patient;
- The outcome is usually favorable without treatment;
- The major forms justify the administration of calcium salts and a sedative (Valium).
3.3. Stroke :
They result from thrombosis or embolism of cerebral vessels leading to infarction and necrosis of brain tissue.
The clinical signs are variable but the most constant are:
- Headache, moderate or severe;
- Nausea and vomiting, dizziness;
- Slow breathing, slow and pounding pulse.
- Neurological deficit (paresis, hemiplegia, aphasia).
Management (treatment is essentially symptomatic):
- Slightly elevate the patient’s head in case of hypertension;
- Clear the airway and administer oxygen if the patient is unconscious or in respiratory distress;
- If symptoms persist for more than a few minutes, contact emergency medical services.
- Allergic reactions
4.1. Urticaria:
Hives can be the skin manifestation of an allergy.
Clinical signs:
- Red or pink papules;
- Itching and local sensation of heat.
Action to take:
- Eliminate the allergen;
- Stop treatment and lay the patient down;
- Inject intravenously a solution of corticosteroids (100 mg of hydrocortisone or 8 mg
intravenous or intramuscular Dexamethasone) or an intramuscular antihistamine (Polaramine® 5 mg: antiallergic antihistamine); – Contact emergency medical services.
4.2. Airway edema, Quincke’s edema : Clinical signs:
- Edema of the face and lips; – Respiratory distress.
Action to take:
- Keep the patient in a sitting position;
- Administer to the patient intravenously a loading dose of corticosteroids such as methylprednisone 1 mg/kg combined with a beta 2- mimetic aerosol (bronchodilator such as Salbutamol: Ventoline®);
- Carry out cardio-respiratory monitoring and ensure oxygenation; – Hospitalize the patient urgently (SAMU).
4.3. Anaphylactic shock:
This is a major allergic hypersensitivity reaction to an antigen (anesthesia, antibiotics, latex, etc.), responsible for circulatory and sometimes respiratory distress that can be life-threatening.
Clinical signs appear within 5 to 30 minutes after administration of the substance – Urticaria;
- Cyanosis;
- Angioedema;
- Sweating related to hypercapnia (increased CO2 ) ;
- Feeling of general malaise; – Hypotension and tachycardia; – Dyspnea with bronchospasm.
Action to take:
- Eliminate the allergen;
- Lay the patient in the supine position;
- Give a subcutaneous injection of adrenaline (0.5 to 1 mg) (Anahelp®).
- Antihistamines can be injected slowly intravenously as a supplement; – Check blood pressure regularly and ensure oxygenation;
- Administer in addition to intravenous or intramuscular hydrocortisone (100 mg) when improvement is observed;
- Sterile tray.
- Sterile compresses.
- Skin antiseptic (povidone iodine, chlorhexidine).
- Syringes of 2, 5, 10 and 20 ml.
- Preparation needles.
- Intramuscular injection needles.
- Intravenous injection needles.
- Subcutaneous injection needles.
- Elastic tourniquet.
- Blood pressure monitor.
- Guédel or Mayo cannula.
- Oxygen cylinder with mask or nasal cannula and regulator.
At a minimum, you should have a stethoscope and a blood pressure monitor (semi-automatic). It is also desirable to have a pulse oximeter. A cardiac defibrillator is not yet mandatory but desirable.
Conclusion :
In the presence of a medical emergency, the practitioner must:
- Have all the emergency equipment and medications available;
- Be able to diagnose a causal pathology, describe it in simple words and take charge of the patient;
- Record the actions and implementation on a protocol with a time record;
- Be aware of your limits and only intervene within the framework of your skills;
- Call or have emergency services called as soon as possible when a serious illness requires it.
Prevention of medical complications during surgery is based on appropriate patient care. A general knowledge of the pathologies that can cause a medical emergency and a detailed knowledge of the medical history are of the utmost importance. The surgical procedure must be carried out in conditions of comfort and calm in order to prevent or alleviate any anxiety of the patient.
Medical emergencies at the dental office.
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