*Academic Year 3*

Medical Emergencies During Dental Treatment

Assistant Prof Dr. Hamid Hammad Enezei
Ph.D in Oral & Maxillofacial Surgery

1
Medical emergencies during dental treatment
Overview of medical emergencies
Basic measures, equipment and drugs
Common emergencies
 Collapse
 Anaphylaxis
 Cardiac arrest
 Diabetic collapse due to hypoglycemia
 Fits and convulsions
 Adrenal crisis
 Acute severe asthma
 Chest pain
Medical emergencies during dental treatment
Medical emergencies that have occurred in dental practices include vasovagal syncope, angina, hypoglycaemia,
epileptic seizures, choking, asthma, anaphylaxis and cardiac arrest.
It is estimated that, on average, a general dental practitioner (GDP) will experience a medical emergency at least
once every two years
Common emergencies
Sudden collapse
Adrenal crisis
Anaphylaxis
Cardiac arrest
Diabetic collapse due to hypoglycemia
Fits and convulsions
Acute severe asthma
Chest pain
Syncope
Risk management can play an important part in reducing the risk of medical emergencies in the dental practice. It is
therefore recommended that all primary care dental facilities have a process for medical risk assessment of their
patients.
Anticipation of potential medical emergencies that may arise should be highlighted by taking a thorough medical
history which is revised, updated and checked each time the patient presents for treatment. It has been suggested that
the presence of an updated medical history may help to minimize the risk of a medical emergency occurring.
Importance of training:
It is essential that all dental professionals must be trained in dealing with medical emergencies, including
resuscitation, and possess up to date evidence of capability .
1-Planning ahead, there should be at least two people available within the working environment to deal with
medical emergencies when treatment is scheduled to take place (in exceptional circumstances, the second person
could be a receptionist or a person accompanying the patient).
2 -Members of the dental team must maintain their knowledge and competence to effectively and safely deal with
a medical emergency, an important aspect of all dental professionals’ continuing professional development
(CPD) once a year .

Vasovagal syncope is the most common emergency encountered. Interestingly, one study showed that 4.8% of all
GDPs observed 22% of all syncopes and that the prevalence of vasovagal syncope tends to decrease with
professional experience
Basic measures, equipment and drugs
Recommended practice
Practices should ensure they have emergency medicines and equipment to keep patients safe.
Professional guidelines: NICE: Prescribing in dental practice (Medical emergencies in dental practice)
1.These should be available to manage common medical emergencies:
1. adrenaline/epinephrine injection, adrenaline 1 in 1000, (adrenaline 1 mg/mL as acid tartrate), 1 mL amps
2. aspirin dispersible tablets 300 mg
3. glucagon injection, glucagon (as hydrochloride), 1 - unit vial (with solvent)
4. glucose (for administration by mouth)
5. glyceryl trinitrate spray
6. midazolam oromucosal solution treated epilepsy
7. medical oxygen
8. salbutamol aerosol inhalation, salbutamol 100 micrograms/metered inhalation.
Professional guidelines: Quality standards: Primary dental care
2.This is the minimum equipment recommended:
2. adhesive defibrillator pads
3. automated external defibrillator (AED)
4. clear face masks for self-inflating bag (sizes 0,1,2,3,4)
5. oropharyngeal airways sizes 0,1,2,3,4
6. medical oxygen cylinder
7. oxygen masks with reservoir
8. oxygen tubing
 2. pocket mask with oxygen port
3. portable suction, for example Yankauer
4. protective equipment – gloves, aprons, eye protection
5. Razor or blade
6. scissors
7. self-inflating bag with reservoir (adult)
8. self-inflating bag with reservoir (child)
9. if there are ampules in the medical emergency drugs kit, there must be adequate numbers of suitable needles
and syringes.
3.Oxygen cylinders should be easily portable but must allow adequate flow rate (for example 15 L min) for thirty
minutes or until the arrival of emergency services. Local policy should dictate the precise size of cylinder and whether
a second cylinder is needed in case the first one is at risk of running out.
4.Quality Assurance Process: At least every week, check:
4. expiry dates for emergency medicines
5. equipment and availability of oxygen. The manufacturer’s instructions must be followed about the use,
storage, servicing and expiry of equipment. A planned replacement programme should be in place for
disposable equipment items that have been used or that reach their expiry date.
Adrenal crisis
People with Addison's disease must be constantly aware of the risk of a sudden worsening of symptoms, called an
adrenal crisis. This can happen when the levels of cortisol in body fall significantly. An adrenal crisis is a medical
emergency. If left untreated, it can be fatal. Patient all the time under steroid therapy
Steroid supplementation is required before the dental treatment to prevent adrenal crisis in a patient with primary
adrenal insufficiency (for example, Addison's disease) undergoing a dental procedure:
•Minor dental procedures (for example, scale and polish, replacement filling) - advise the patient to take an additional
oral dose of glucocorticoid one hour before their appointment
•More complex dental procedures (for example, root canal work under local anaesthetic) - prescribe steroid
supplementation before the procedure and for a full 24 hours afterwards
•Dental extractions and minor oral surgery - refer to secondary care.
Patients with primary adrenal insufficiency should be advised to bring their emergency hydrocortisone injection
kit to all dental appointments, as well as their personalised adrenal crisis letter which provides medical treatment
guidance.
If the patient develops adrenal crisis, call health emergencey line immediately, stating 'Addisonian crisis', and if
the patient's emergency hydrocortisone injection kit is available, administer intramuscular (IM) hydrocortisone. The
recommended dose, which should be stated on the patient's adrenal crisis letter, depends on the patient's age:
•Adults: 100 mg
•Children six years of age or older: 50-100 mg (use clinical judgement depending on the age and size of the child)
•Children one to five years of age: 50 mg
•Infants up to one year of age: 25 mg.
Anaphylaxis
Anaphylaxis is a body reaction to some thing causes the immune system to release a flood of chemicals that can
cause you to go into shock — blood pressure drops suddenly and the airways narrow, blocking breathing. Signs and
symptoms include a rapid, weak pulse; a skin rash; and nausea and vomiting.

Anaphylaxis is likely when all of the following 3 criteria are met:

•Sudden onset and rapid progression of symptoms.
•The person will feel and look unwell.
•Most reactions occur over several minutes. Rarely, reactions may be slower in onset.
•The time of onset of an anaphylactic reaction will depend on the type of trigger. For example, an intravenous trigger
will cause a more rapid onset of reaction than stings, which tend to cause a more rapid onset than orally ingested
triggers.
•The person will appear anxious and can experience a 'sense of impending doom'.

Anaphylaxis is a clinical diagnosis; a precise definition is not important for treatment.

Recognise anaphylaxis based on:
•Sudden onset and rapid progression of symptoms
•Airway and/or Breathing and/or Circulation problems
•Skin and/or mucosal changes (flushing, urticaria, angioedema) – but these can be absent in up to 20 per cent of cases.
Signs and symptoms
•Airway problems: lip and tongue swelling/angioedema, nasal congestion, sneezing, tightness of throat/hoarse voice/stridor
•Breathing problems: increased respiratory rate, bronchospasm causing wheeze, increased mucous secretions, exhaustion,
cyanosis, respiratory arrest
•Circulation problems: low blood pressure, fast heart rate (tachycardia), arrhythmia, chest pain, cardiac arrest
•Disability/Neurological problems: confusion, agitation, loss of consciousness
•Exposure – skin and mucosal: urticaria, erythema, pruritus
•Gastrointestinal: stomach cramps or spasm, nausea, vomiting, diarrhoea
•Other: feeling of impending doom

Differential diagnosis:
Commonly anaphylaxis can be mistaken or confused for:
•Asthma (can present with similar symptoms and signs to anaphylaxis, particularly in children)
•Septic shock (hypotension with petechial/purpuric rash)
•Vasovagal episode
•Panic attack or hyperventilation syndrome
•Idiopathic (non-allergic) urticaria or angioedema

Management

Scenario: Angio-oedema without anaphylaxis

How should I manage a person with angio-oedema without any airway
symptoms or signs of circulatory collapse?

For people with rapidly developing angio-oedema without anaphylaxis:

•Give slow intravenous (IV) or intramuscular (IM) chlorphenamine and hydrocortisone.
•Arrange emergency hospital admission.
•Arrange a review after the person has been discharged from hospital.
For people with stable angio-oedema without anaphylaxis:
•Try to identify the underlying cause so that further episodes can be avoided.
• For people taking an angiotensin-converting enzyme (ACE) inhibitor:
• Stop treatment immediately, and consider starting an alternative drug treatment.
• If possible, avoid angiotensin-II receptor antagonists as these can also trigger episodes of angio-oedema.
•For people with mild symptoms of angio-oedema, treatment may not be needed.
•For people with symptoms requiring treatment:
• Offer a non-sedating antihistamine (such as cetirizine, fexofenadine, or loratadine) for up to 6 weeks (use
clinical judgement to determine the duration of treatment).
• If symptoms are severe, give a short course of an oral corticosteroid (for example prednisolone 40 mg daily
for up to 7 days) in addition to the non-sedating oral antihistamine.
• Advise the person to seek immediate medical help (by dialling EMERGENCEY LINE or attending A&E) if
symptoms progress rapidly or if symptoms of anaphylaxis develop. e.
•Refer the person to a dermatologist or immunologist if:
• Hereditary or acquired angio-oedema is suspected.
• Symptoms persist or reoccur 3 months after stopping treatment with an ACE inhibitor.
• The cause of angio-oedema is not identifiable or avoidable.
•For people awaiting specialist review who are at risk of anaphylaxis, seek specialist advice about prescribing an
adrenaline auto-injector device to be used in the event of anaphylaxis before their hospital appointment.
• People at risk of anaphylaxis include people with co-existing asthma, chronic obstructive pulmonary disease,
or heart disease, people who have experienced angio-oedema with trace amounts of an allergen/trigger, and
people who cannot easily avoid an allergen.
• If an adrenaline auto-injector device is indicated in a person taking a beta-blocker, consider discontinuing the
beta-blocker if possible, as it can interfere with the action of adrenalin

Scenario: Anaphylaxis with or without angio-oedema

If a person presents with features of anaphylaxis with or without angio-oedema:
•Treat as a medical emergency. Call for an ambulance and ask for help from colleagues.
•Assess the person.
• Look for and relieve airway obstruction.
• Check for normal breathing.
• If the person is unresponsive and not breathing normally:
• Start cardiopulmonary resuscitation (CPR) immediately.
•Repeat the IM adrenaline dose after 5 minutes if there is no improvement in the person's condition.
•If there is no improvement after two IM doses, give IM adrenaline every 5 minutes until there has been an
adequate response.
•Do not give intravenous (IV) adrenaline in primary care.
•Remove the trigger if possible.
•For example, remove the stinger after a bee sting. Early removal is more important than the method of removal.
•After food-induced anaphylaxis, attempts to make the person vomit are not recommended.
•Do not delay definitive treatment if removing the trigger is not feasible.

•Where skills and equipment are available:

•Give oxygen at the highest concentration possible as soon as available using a mask with an oxygen reservoir.
•Adjust the inspired oxygen concentration to achieve an oxygen saturation of 94-98% (in people at risk of hypercapnic
respiratory failure, consider a target range of 88-92%).
•Attach monitoring (pulse oximetry, blood pressure, ECG) as soon as possible — this will help assess the person's response to
adrenaline.
•In the presence of hypotension/shock, or poor response to an initial dose of adrenaline obtain IV access and give a rapid IV fluid
bolus (for example, with Hartmann's or normal saline) using 500–1000 mL in an adult, or 10 mL/kg in a child.​ Give further fluids
as necessary.
•Consider inhaled salbutamol or ipratropium therapy if the person is wheezy (especially in people with known asthma).
•Arrange a review after the person has been discharged from hospital. See the section on Follow up for more information.
•Ensure that help is on its way as early advanced life support is essential.
•For people who do not require CPR:
•Examine the chest for signs of lower and upper airway obstruction.
•Check the pulse and blood pressure for signs of circulatory collapse.
•Check the skin and inside the mouth for urticaria and angio-oedema.

•Place the person in a comfortable position — take into account the following factors:
•Fatality can occur within minutes if the person stands, walks or sits up suddenly. They must not walk or stand during
acute reactions. Use caution when transferring people who have been stabilized.
•People with airway and breathing problems may prefer to be in a semi-recumbent position, as this will make
breathing easier.​
•Lying flat with or without leg elevation is helpful for people with low blood pressure.
•Place people who are breathing normally and unconscious on their side (recovery position).​ Monitor breathing
continuously and prepare to intervene if this changes.
•Pregnant women should lie on their left side to prevent aortocaval compression.​

•Give intramuscular (IM) adrenaline 1:1000 as per age-related guidelines.

•The injection can be given in the anterolateral aspect of the middle third of the thigh (ideally) or arm, depending on
access.
•Assess the response to treatment after 5 minutes — measure vital signs (respiratory rate, oxygen saturations, heart
rate, BP, level of consciousness) if possible and auscultate for wheeze.
Cardiac arrest:
As oral health professionals, being prepared can spell the difference between life and death for patients experiencing
a cardiac emergency in the dental office. The general populations’ increasing overall age (and subsequent medical
involvement) raise the probability of encountering sudden cardiac arrest in oral health care settings.
Once the heartbeat becomes arrhythmic, defibrillation is the only resolution. An automated external defibrillator
(AED) is an essential tool in every dental office to manage these situations.

Early defibrillation with these easy-to-operate devices will convert two of the most common lethal cardiac
dysrhythmias, ventricular fibrillation and ventricular tachycardia, into a normal sinus rhythm and restore
oxygen perfusion to vital organs.

Survival rates decline by 7% to 10% with each passing minute an affected individual goes without defibrillation.
Sudden cardiac arrest and sudden cardiac death (SCA/SCD) involve the rapid arrest or death of an individual due to
cardiovascular-related issues.

The heart’s electrical rhythm becomes chaotic — either through ischemic provocation or another arrhythmic
trigger — and ultimately stops beating.
Congestive heart disease is the most common underlying pathology for sudden cardiac arrest in adults over the age
of 35.
Risk factors for congestive heart disease, including diabetes mellitus, obesity, hypertension and high
cholesterol, have a direct relationship with these events.
Diabetes plays a role in the development of cardiovascular disease by increasing the amount of blood and workload
placed on the heart. Its chambers are damaged through excessive dilation and hypertrophic enlargement, making
each pump strenuous.
Obesity increases the incidence of lethal arrhythmia and atrial fibrillation by structurally damaging the heart.
When obesity and hypertension coexist, the heart grows even larger as its chamber volume is filled beyond
capacity.
Sudden cardiac death in young people, who may be affected by congenital cardiac structural abnormalities, is
typically associated with high cholesterol.

Dental teams should be able to recognize the physical manifestation of cardiac arrest or clinical death, including
loss of consciousness, sudden collapse, or a lack of pulse and breathing. Making certain that staff members hold
current Basic Life Support (BLS) for Healthcare
Providers certification, and equipping all dental facilities with an AED, emergency kit and monitoring equipment —
as well as developing and rehearsing an emergency action plan — will provide these patients with the

Dental staff should be suspicious of cardiac arrest in any patient presenting with seizures. On confirming cardiac
arrest, stay with the patient and start chest compressions immediately while asking colleagues to call health
emergency line for an ambulance and to fetch automated external defibrillator (AED)/resuscitation equipment
High-quality chest compressions
High-quality CPR performance metrics include: Chest compression fraction >80% Compression rate of 100-
120/min.
Compression depth of at least 50 mm (2 inches) in adults and at least 1/3 the AP dimension of the chest in infants and
children
•Start chest compressions as soon as possible.
•Deliver compressions on the lower half of the sternum (‘in the center of the chest’).
•Compress to a depth of at least 5 cm but not more than 6 cm.
•Compress the chest at a rate of 100–120 min with as few interruptions as possible.
•Allow the chest to recoil completely after each compression; do not lean on the chest.
•Perform chest compressions on a firm surface whenever feasible.
Rescue breaths
•If you are trained to do so, after 30 compressions, provide 2 rescue breaths.
•Alternate between providing 30 compressions and 2 rescue breaths.
•If you are unable or unwilling to provide ventilations, give continuous chest compressions.
Compressions before defibrillation
•Continue CPR until an AED (or other type of defibrillator) arrives on site and is switched on and attached to the
person.
•Do not delay defibrillation to provide additional CPR once the defibrillator is ready.
Fully automatic AEDs
•If a shock is indicated, fully automatic AEDs are designed to deliver a shock without any further action by the rescuer.
The safety of fully automatic AEDs has not been well studied.
Safety of AEDs
•Many studies of public access defibrillation have shown that AEDs can be used safely by bystanders and first
responders. Although injury to the CPR provider from a shock by a defibrillator is extremely rare, do not continue chest
compression during shock delivery.
Safety
•Make sure you, the person and any bystanders are safe.
•Members of the public should start CPR for presumed cardiac arrest without concerns of causing harm to those not in
cardiac arrest.
•Members of the public may safely perform chest compressions and use an AED as the risk of infection during
compressions and harm from accidental shock during AED use is very low.

automated external defibrillator

Diabetic collapse due to hypoglycemia
Dental practices have a mandatory requirement to keep medication and equipment to monitor and treat
hypoglycemia.

This includes blood glucose monitors, oxygen and masks, glucose tablets, glucogel and glucagon.

If a patient is showing signs of low blood sugar or the results of a blood glucose test are less than 3mmol per liter
then the following regime should be adopted.

If a patient is conscious and cooperative give them a glucose drink or tablets to chew.

If the patient is conscious but uncooperative then administer a tube of glucose gel in the buccal sulcus.
If however, the patient is unconscious then call the ambulance and administer glucagon intramuscularly.
Glucagon is a hormone which helps to raise blood glucose levels. It is the opposite of insulin which lowers blood glucose levels.
Glucagon kits consist of a vial of 1 mg of freeze-dried glucagon and a syringe containing a 1 ml of diluting solution.

The kit should be stored at a temperature of 2–8°C in a refrigerator, but it must not be frozen. If stored in the refrigerator the
shelf life from the manufacturer is 36 months.

Glucagon kits can be stored outside the refrigerator at a temperature not exceeding 25°C for 18 months provided that the
expiry date is not exceeded.

It should be stored in the original package in order to protect from light. This is common practice as it needs to be easily
accessible for emergency use.

However DENTAL PROFESSIONAL must be able to demonstrate either when the product was out of refrigerated storage, for
example, label the product with the date it was taken out of the fridge or a revised expiry date, or how the product is safe for use,
for example by referring to the purchase invoice showing that 18 months has not elapsed from delivery.

In addition, if you are storing the glucagon kit in the fridge you must ensure that the fridge is monitored and that weekly checks are
carried out to limit the temperature range between 2-8 degrees centigrade. No food items or laboratory items should be stored in
the same fridge.
Once glucagon has been administered, oxygen can be given and the patient monitored with special attention to
the airway. On recovery, a glucose drink and a complex carbohydrate can be given whilst awaiting the
ambulance services.
As always it is better to carry out risk assessments for diabetic patients and a detailed medical history and
checking whether patients have eaten before appointments will often prevent problems occurring.

Fits and convulsions

A seizure is defined as a fit or convulsion that occurs when a sudden burst of electrical activity in the brain
temporarily interferes with the normal messaging processes. The brain controls the whole body, so depending on
where the seizure occurs in the brain, different parts of the body may be affected.
There are many different types of seizures and a multitude of causes. Any head injury or stress to the brain can
cause fitting, as can brain tumours, meningitis, malaria, eclampsia in pregnancy, poisoning, lack of oxygen,
raised body temperature, epilepsy as well as drug and alcohol use and withdrawal.
It is possible that someone experiencing a cardiac arrest may appear to have a seizure as their brain struggles
with depleted oxygen – always ensure they are breathing.
It is particularly common for babies and young children to experience febrile convulsions. These are seizures
triggered by a rise in temperature when the child is unwell. These seizures don't usually cause any long-term
problems and the child usually grows out of their pre-disposition.
Observing how someone behaves during a seizure can often be extremely helpful to aid the neurologist's diagnosis
and treatment.
Different types of seizures
Fits, seizures or convulsions can take many forms. They may cause rigid out of control movements; the casualty may experience
absence seizures where they become rigid and unresponsive; there may be full thrashing around tonic/clonic fits; or anything in
between.
How to help someone experiencing a tonic-clonic fit or generalized seizure

What might happen

Tonic phase – the casualty will collapse as they lose consciousness. The body goes stiff and rigid and they may cry out as if in
pain. This is due to an involuntary action as the muscles force air out of the lungs – the casualty is not in pain and is usually
unaware of the noise they are making. They can begin to appear blue around their mouth and finger tips.
Clonic phase – They may rigidly jerk around as the muscles alternately relax and tighten. They may make a snoring noise as the
tongue flops to the back of the airway; they could be incontinent and might bite their tongue.
Post-ictal phase – Once the jerking stops, they may be confused, sleepy, agitated or relatively unresponsive (if you are worried
about their airway put them into the recovery position).

Help for a generalized seizure in a dental practice

1-Clear all dental instruments away from the patient.
2-If the patient is on the dental chair: place the dental chair in a supported, supine position as near to the floor as possible. If the
patient is not on the chair, ease them onto the floor and protect their head from injury by gently cushioning with a pillow or coat.
Move things away from them to protect from injury. If dental treatment has begun, try and ease the patient onto their side to reduce
the possibility of them aspirating secretions and recent dental work.
3-Do not restrain the patient.
4-Do not put your fingers in his or her mouth (you might be bitten), or try and put anything in their mouth for them to bite on.
5-Time the seizure. Call the emergency services if the seizure lasts longer than five minutes or the patient
experiences repeated seizures.
6-Loosen any tight clothes around their neck and loosen belts. Protect the patient's dignity.
7-Call the emergency services if the patient looks cyanotic [blue] from the onset.
8-Administering oxygen may be helpful.
9-If the seizure lasts longer than five minutes or for repeated seizures, administer buccal midazolam or
appropriate emergency anti-epileptic drugs from your emergency drugs. Contact the emergency services if
unsure.
10-Be aware of the possibility of compromised airway or uncontrollable seizure.

Once the seizure has finished, place the patient in the recovery position, on his or her side. These guidelines
should also be followed:

1-Do not undertake further dental treatment that day.

2-Try to talk to the patient to evaluate the level of consciousness during the post-ictal phase.
3-Do not attempt to restrain the patient, as he or she might be confused.
4-Do not allow the patient to leave the practice until you are sure they have made a full recovery.
5-Contact the patient's family, if he or she is alone.
6-Do a brief oral examination for sustained injuries.
7-Depending on post-ictal state, discharge the patient home with a responsible person, to his or her family physician
or call the emergency services.
Acute severe asthma
An acute episode of asthma in the dental office may be precipitated by extrinsic factors such as inhaled allergens,
as well as intrinsic factors such as fear or anxiety.
An asthma episode should be considered a medical emergency and must be treated promptly by inhalation of a
bronchodilating agent.
A history of asthma in the dental patient should alert the dentist to implement strategies that may prevent an acute
attack and to be prepared to manage this potentially life-threatening medical emergency appropriately. The chronic
use of bronchodilating inhalers and/or glucocorticoids for the management of asthma can increase the likelihood
of oral candidiasis, particularly in patients who have additional risk factors such as smoking, denture use, or the
use of xerostomic medication
GUIDELINES TO BE FOLLOWED
A) BEFORE TREATMENT
1.Patients appointment should be late morning or afternoon.
2.Assess severity of ASTHMATIC condition.
3.Consider antibiotic prophylaxis for immuno-suppressed patients.
4.Consider corticosteriod replacement for adrenally suppressed patients.
5.Avoid using dental materials that may elicit an ,Asthmatic attack i.e. dentifrices
,Fissure sealants ,Methyl meth acrylate, Fluoride trays & cotton rolls can trigger
Asthmatic events.
6.If asthmatic patients does not use a broncodilator ,make sure the emergency kits has both a bronchodilator & oxygen.
B) DURING TREATMENT
1.Rubber dams should be used cautiously.
2.Use technique to reduce patient stress:
•Avoid prolonged supine positioning
•Avoid nitrous oxide in people with severe ASTHMA.
•Avoid using BARBITURATES.
3.Avoid using LA containing SODIUM METABISULFIDE.
4.Use vasoconstrictor judiciously.
C) AFTER TREATMENT
1. Be cautious while prescribing NSAID to ASTHMATIC patient.
2.TETRACYCLINE should be used cautiously.
3.Avoid use of ERTHROMYCIN in patients taking THEOPHYLLINE.
4.Avoid use of PHENOBARBITALS in patients taking THEOPHYLLINE.
5.Analgesic of choice for these patients is ACETAMINOPHEN.
WHAT TO DO DURING ACUTE ASTHMATIC ATTACK IN DENTAL CLINIC OR HOSPITAL?
1. Allow patient to assume a comfortable position & discontinue the dental procedure.
2.Establish & maintain patient airway & administer beta2 agonists VIA inhaler or nebulizer.
3.Administer oxygen 6-10 liters VIA face-mask, nasal hood or cannula.
if no signs of improvement is absorbed & symptoms are worsening ,administer EPINEPHRINE subcutaneously (1:1,000 solution
,0.01 milligram/kg of body weight to a maximum dose of 0.3mg)
4.Alert medical emergency service.
5.Maintain a good oxygen level until the patient stops,wheezing /or medical assistance arrives.
6.Begin basic life support C,A,B & D 's activity as needed.
Acute chest pain :
The most common causes of acute chest pain encountered in dental situations include hyperventilation, pulmonary
embolism, angina pectoris and myocardial infarction. Stress and fear often cause rapid breathing or
hyperventilation .
Cause:
Diminished blood supply to myocardium due to an imbalance between myocardial oxygen supply and demand.
Signs/Symptoms:
Chest pain – substernal pressure or crushing sensation. May radiate to neck, left shoulder and down arm, and left side
of jaw. About 10% of heart attacks report jaw pain as a symptom. Though, that is usually throughout the jaw and
not localized to a single tooth.
The most common description is pain throughout the lower jaw. Some people describe this pain but don’t have
any accompanying chest pains, yet they were still having a heart attack. It is always better to have pain looked at.
Each person’s anatomy and responses vary. There isn’t a single common symptom to look out for.
Some Other Symptoms of a Heart Attach
•Pressure, tightness, pain, or a squeezing or aching sensation in your chest or arms that may spread to your neck, jaw
or back
•Nausea, indigestion, heartburn or abdominal pain
•Shortness of breath
•Cold sweats
•Fatigue
•Lightheadedness or sudden dizziness
The two cardiovascular conditions that cause
most deaths are ischemic heart disease and
cerebrovascular disease, with heart failure in
third place. In addition to their associated
morbidity, such disorders are important due to the
number of affected individuals and the many
patients subjected to treatment because of them.
Patients with cardiovascular disease constitute risk
cases in dental practice, particularly in the absence
of adequate medical control.

Treatment of Angina:

1) Terminate procedure - The stress of the

procedure itself might be what increases the heart
rate, and precipitates angina. Sometimes, just
halting the procedure, or removing the stressful
stimulus (syringe, hand piece, etc) will allow the
angina to resolve itself.
2) Position the patient - The patient in angina is
usual conscious and apprehensive.
Position the patient in the most comfortable position, which is usually sitting up. Lying down for this patient, usually makes
the pain feel more intense.
3) Administer Oxygen - Since the cause of the problem is a relative lack of oxygen to the heart muscle, any thing that increases
the amount of oxygen in the blood stream will increase the amount of oxygen the heart muscle receives. Administering oxygen via
a nasal hood or canula is an easy way to do this.
4) Administer Nitroglycerin(NTG) - Nitroglycerin is a potent vasodilator, expecially for the cardiac vessels. This opening of the
cardiac blood vessels allows more oxygen rich blood to reach the heart. The dose is 0.4mg either by pill or metered
spray sublingual.

There are two precautions.

First is a real contraindication. Patients that have taken a phosphodiester inhibitor medication such as Viagra or Cialis, in
the last 48 hours should not be given nitroglycerin. There are synergistic effects from these drugs that can result in a severe,
life threatening hypotension.

The second is a precaution with hypotensive patients. NTG has effects on the whole body, and a more generalized vasodilation
can lead to hypotension. If the patient is already severely hypotensive, administering NTG may exacerbate the hypotension.

Patients with systolic blood pressures below 110 or more than 30% below the patients baseline may need to be placed flat or
given a IV fluid bolus prior to administering NTG. This may be impractical in your office and best to wait for EMS to
arrive.
4) Repeat NTG q3-5 minutes after three doses, you have to suspect that this is not angina, and is a true heart
attack/myocardial infarction(MI) occurring. Procede to treatment of an MI you should follow.
5) Modify dental therapy to prevent recurrence. Administer oxygen while treating the patient, and using stress reduction
protocols.
Stress Reduction Protocol
Seventy Five percent of emergencies in the office are stress related. Most patents have the capacity to deal with
this increase in stress. However, our medically compromised patients have less capacity to deal with it.
The body's response to dental stress increases the cardiovascular workload and metabolism, which puts stress on
the respiratory and endocrine systems. Together, these can overwhelm the compromised patient's ability to deal
with this stress. To minimize the stress to the patient, the stress reduction protocol was established.

The Stress Reduction Protocol

Short Appointments - Some people only have so much tolerance for dentistry. Don't go into "overtime" with
these patients. Short appointments, may be best for them.
Profound Local Anesthesia - It's obvious how this reduces stress. Work on having multiple techniques for local,
different anesthetics and differnent technique. Not all patients respond to one type of local or one technique of
administration.
Supplemental Oxygen - Increasing the blood level of oxygen makes more available to the heart, lungs and
brain. Even if cardiac, respiratory or metabolic workload goes up. There is more oxygen available for these organ
systmes to work.
Pre-op Sedatives - Sedated patients are calm patients. Used appropriately, sedated patients have a fewer spikes
in pulse and blood pressure, which decreases cardiac, respiratory or metabolic workload.
Sedation during appointment - See above.
Prophylactic Meds - These optimize the patient's cardiac, respiratory or metabolic system before treating them.
•Inhalers , Glucose ,Nitroglycerin
 Pre Op Vitals - Comparison of these values to base line vitals taken at an earlier visit serve as a physical status on
any givent day. In addition to pre-op pulse and blood pressure, I like to get a blood sugar in my diabetic patients.
Syncope:
Vasovagal syncope (VVS), known as common faint, is a neurally mediated syndrome associated with hypotension
and relative bradycardia due to cerebral hypoperfusion.
Syncope is the most common emergency in dental practices. Nonetheless, the vast majority of dentists do not
seem competent nor prepared to manage this emergency.
Psychogenic factors seem to play an important role in provoking syncope. Placing the patient in a supine reclined
position with raised legs in combination with the administration of oxygen seems effective for regaining
consciousness.
Although valuable in many aspects, risk assessment by medical history taking is not proven to result in fewer
episodes. The strength of these conclusions is low based on GRADE guidelines

Causes:
 External fluid loss;
 Internal sequestration of fluid;
 Decrease in cardiac output;
 Arrhythmias;
 Hypocapnia (hyperventilation);
 Hypoglycemia.
Signs/Symptoms:
1. Blood pressure low normal or elevated; Tachycardia.
2. Orthostatic hypotension and increased pulse rate.
3. Altered mental states; anorexia; apathy, weakness.
4. Cold clammy skin.

Treatment:
1-proposes early intervention by placing the patient in a supine position with feet elevated 10° whilst maintaining an
open airway in order to reinstate cerebral perfusion
2-Maintain patient airway – turn head to one side to prevent aspiration.
3-Administer 100% oxygen.
1. DO NOT use aromatic spirits of ammonia because it stimulates the sympathetic system and augments
arrythmogenicity.
Prevention:
Dentists and other oral health care workers have an important role to play since they are responsible for: (1)
preventing episodes from (re)occurring, (2) diagnosing and differentiating between banal or severe incidents and (3)
acting adequately to regain one's consciousness. In most clinical situations however, dental practitioners don't feel
confident handling such medical emergencies.
Low confidence in managing emergencies is associated with insufficient training or education.The common
absence of a blood pressure monitor, electrocardiogram (ECG) monitor or an on-site specialist in dental practices
poses an additional challenge to the practitioner.