Emergencies in dental Practice

Emergencies in dental Practice

What is an emergency?

Emergency is a condition that warrants ar immediate attention by the doctor. This situation is an unexpected one under unforeseen circumstances and calls for an gent treatment. Fortunately, medical emergencies are of rare occurance in the dental office. Many emergency problems an definitely be avoided by simple preventive measures like a careful medical history, general physical examination regarding patient's health status and proper pre-operative preparation of the patient. The patient should be closely observed during all surgical procedures. howsoever minor these procedures may be or the onset of a potential emergency.

Inspite of best preventive measures aken by the dentist and his staff, emergencies do occur in dental office and need immediate management. The dentist must update his knowledge and keep himself prepared to fight against these. situations.

General consideration-

To handle any type of emergency in the dental office, the dentist must keep certain things in mind. One must not ignore the fact that the emergencies have occurred in dental office and these do occur may be infrequently and dentist has to manage the situation. To prepare himself for combating with these conditions a dentist must-

1)Understand the various emergency problems associated with dental procedures.

2) Early recognise the condition arising .

3) Start management as soon as condition is recognised.

4) Adopt preventive measures to avoid such like situations in the setup.

A comprehensive medical history of the patient must be recorded to identify the medically compromised patients. If need be, a contact with the physician of the patient should be established to know the correct health status and the associated problems.

The dentist must be alert to watch for any onset of emergency in his clinic before. during or after treatment procedure Surgical team should closely observe the patient for institution of emergency measures to save life of the patients.

Following steps must be observed carefully and immediately-

Send the call to the physician immediately.

Make the patient lie down in a comfortable posture, preferably in supine position with the head low or tilted to one side.

Maintain a patent airway.

Oxygen is thr best medicine for all life threatening emergencies and should be given under positive pressure for resuscitation.

Life saving medicines should be judiciously used and a record must be maintained.

All vital signs should be monitored and properly recorded.

During this procedure the doctor and his team must keep the mind cool and concentrate on successful management without getting panicky.

A list of medicines should be pasted on the cupboard.

The various medicines and equipment for the purpose are listed below-

MEDICINES-

1) Oxygen

2)Aromatic spirit of ammonia

3)Tablet Trin

4 )Inj. Calmpose/Diazepam,( 5 mg/ml)

5) Inj.Atropine 0.65 mg/ml (1 ml ampoule)

6) Inj. Adrenaline 1:1000 solution (1 ml ampoule)

7) Inj. Sodium bicarbonate 7.5%( 50 ml vial)

8)Inj. Xylocaine hydrochloride 1%, 2% (30 ml vial)

9) Inj. Pentazocine lactate( Fortwin) 30mg (1 ml ampoule)

10). Inj. Diclofenac sodium (3ml ampoule) 50mg/ml

11) Inj. Dexamethasone sodium phosphate (Decadron) 4 mg/ml (2 ml vial)

12) Inj. Hydrocortisone sodium succinate(100 mg)

13) Inj. Chlorpheniramine maleate (Avil) 23.75 mg/ml (2 ml ampoule)

14) Inj. Frusemide (Lasix) 10mg/ml (2 ml ampoule)

15) Inj. Novalgin (Analgin) 0.5 gm/ml (2ml ampoule)

16) lnj. Deriphyllin (Theophylline 50.6 mg/ml and Etofyline 169.4 mg/ml)

17) Inj. Nikethamide (coramine) 0.25 gm/ ml (2ml ampoule)

18) Inj Phenergan ( promethazine hydrochloride)

19) sterile water for injection 30 ml vial, 3ml ampoule

20) Inj. Aminophylline 250 mg/10 ml (10ml ampoule)

21) Inj.Dextrose 5%, 10% and 50% (500 ml bottles)

22) Inj .Succinyl choline 20 mg/ml (10 ml vial)

23) Inj. Pentothal sodium.

24) Inj. Ketamine.

EQUIPMENT

1. Equipment to administer oxygen

2. Oropharyngeal and nasopharyngeal airway

3. Endotracheal tubes and connections

4. Laryngoscope and blades with dry battery cells

5. Suction apparatus with tubing and suction tips

6.Scalpel blade and handle

7 Tracheotomy

8 Disposable syringes 2 cc, 5 cc, 10 cc and 50 cc.

9. Blood and glucose administration sets.

10. Hypodermic needles No.23, 25

11. Scalp vein cannula No. 20,23

12. Intravenous catheter No.18, 20

13. Stethoscope

14. Sphygmomanometer 15. Hemostat

16. Suturing thread/Needle holder & scissors

17. Ribbon gauze, surgipads and bandages.

18. Measuring tape

19. Micropore adhesive tape/leukoplast

20. Alcohol sponge .

MEDICAL EMERGENCIES-

SYNCOPE

It is a transient loss of consciousness due to cerebral anoxia. It is also labelled as fainting, common fainting attack or Vasovagal attack. It is perhaps the most common untoward accident seen in the dental office.

Predisposing factors-

Fainting is more commonly seen in younger individuals. It is also seen in people who have poor health. The other. predisposing factors are anxiety, fear, sight: of blood, pain, exhaustion, fasting and hot environment. These emotional stresses induce release of increased amount of catecholamines, Resultantly, there is lower peripheral resistance and hence peripheral pooling of blood and fall in blood pressure,leading to a sudden decrease in cerebral blood flow and when the subject is in the upright position, it falls below 50 mm of Hg for a few seconds, syncope results. Fainting is provoked most readily in standing position less so in sitting position.

Precipating factors-

The chief cause of fainting is cerebral anoxia or anaemia. A blood loss to the tune of one litre will cause fainting in majority of the subjects. The dilatation of the blood vessels with resultant peripheral pooling of the blood can also cause cerebral ischaemia. The splanchnic vessels alone, when fully dilated can accommodate almost the entire blood content of the body. In a way it simulates haemorrhage because it can precipitate fainting

Other factors that may precipitate fainting are fear, sight of blood, severe pain, prolonged attentive standing, consumption of alcohol as it is a vasodilating drug, spinal anaesthesia and supine position in late pregnancy. These factors induce a vasodepressor reaction that causes dilatation of blood vessels in the skeletal muscles and splanchnic region. There is fall in peripheral resistance with decreased venous return to the heart. The arterial pressure falls, the vagal reflexes are activated leading to bradycardia, reduced cardiac output and hypotension. The cerebral ischaemia develops.

Signs and symptoms-

A patient feels weakness, warmth, nausea and pain in the epigastrium and hunger etc before fainting .Following this sweating, dizziness, pallor, light headedness and low pulse pressure develops. If the treatment is not instituted at this stage, unconsciousness develops with ashen grey colour of the skin, shallow respiration, low blood pressure and weak pulse etc.A standing patient falls down. The voluntary musculature is relaxed. There may be associated clonic jerks of the arms so twitching of the facial muscles.

Treatment-

When a patient presents with signs of fainting, he/she should be made to le down in supine position with legs raised improve venous return to the heart. In case the patient is sitting in the dental chair, the back of the chair should be immediately lowered so that the head of the patients at a lower level than the feet. It helps venous return to the heart and oxygenated blood to the brain. Tight clothing should be loosened. A patent airway should be maintained. Any foreign body, mucus or excessive saliva should be removed manually or with suction apparatus. The lower jaw should be maintained in a forward position. Inhalation of aromatic spirit of ammonia or application of cold sponges to the face helps in securing reflex stimulation.

If the surgeon has failed to note the onset of symptoms and suddenly finds the patient unconscious with convulsive movements of extremities due to cerebra hypoxia, the above mentioned steps are carried out without any further delay Additionally if the cyanosis is developing 100% oxygen should be administered. The vitals are recorded. If there is bradycardia. injection atropine 0.6 mg diluted in 5 ml of sterile water should be slowly gives intravenously. In case hypotension persists vasopressor drugs like phenylephrine er methoxamine should be administered.

In case unconsciousness persists for a longer duration than 5-10 minutes, causes other than vasovagal syncope should be considered. After the complete recovery, patient should be slowly brought to semireclining than sitting position.

Prevention-

It is the best way to treat syncope. Syncope usually occurs in sitting position. So it is usually advisable to carry out dental procedures in supine or semireclining position. The role of premedication before anaesthesia and minor surgery should be considered. The patient should be advised to attend the dental clinic neither fasting nor on full stomach if sedation or general anaesthesia are not to be given. A patient who is fasting is more prone to vasovagal fainting.

SHOCK

It is a clinical phenomenon marked by circulatory deficiency which is either cardiac or vasomotor in origin exhibiting marked hypotension. If the primary shock or syncope is not tackled and allowed to persist, the secondary or true shock appears. It can be seen in the dental office on account of variety of reasons

Haemorrhagic shock because of massive internal or external bleeding.

Hypovolemic shock due to fluid loss as in severe burns and dehydration due to vomiting and diarrhoea.

Cardiogenic shock because of various cardiac ailments.

Septic shock due to toxaemia.

Anaphylactic shock due to drug reaction.

Neurogenic shock following syncope.

Signs and symptoms-

The patient is unconscious with ashen grey face and cold clammy skin. Mucous membrane is pale whereas lips, nails, finger tips and lobules of the ear are greyish blue. Face is expression less with sunken eyes. Pupils are dilated but react feebly to light. Pulse is weak and thready. Respiration is shallow, irregular and rapid. Temperature is subnormal.

Shock in the initial stages is reversible and the patient comes out of it if the resuscitation measures are instituted at the earliest. A non-reversible shock proves fatal. It is rightly said that shock can be more easily prevented than treated.

Treatment

It is important to establish the cause of the shock like loss of blood, extremely painful stimulus, emotional reason, toxaemia or anaphylaxis etc. The step by step treatment of shock should be aimed at preventing and treating the hypoxia of vital organs

1. Put the patient in shock position with head at lower level than the feet (15° Trendlenberg position),

2 Maintain the body heat by covering the patient with blanket and keep a hot water bottle between the thighs or on lower abdomen.

3. Check for the patency of the airway, Obstruction if any, should be cleared and the patency of airway be maintained.

4. Control the loss of blood in haemorrhagic shock by pressure packs, ligation of vessels or crushing of bone etc.

5. Restore the lost body fluids, replace blood with blood. In case blood is not readily available, infusion with plasma expanders or Ringer's lactate solution should be carried out to maintain the intravenous line and restore the volume loss. In the meantime blood should be arranged as well as hematocrit is got done.

In case red blood cells are not lost as in burns and dehydration then plasma or plasma volume expanders are used as substitutes. If haemoglobin has fallen due to toxaemia but there is no blood loss, packed cells are given.

6. Administer 100% oxygen to the patient for adequate oxygenation of the body tissues and vital centres. It also helps to maintain body metabolism and hence body heat.

7. The blood pressure, pulse rate and respiratory rate should be monitored to assess the vitals .

8. Injection hydrocortisone sodium hemisuccinate 100 mg dissolved in 5 ml of sterile water is given intravenously .

9. Injection mephentermine is given for hypotension yo elevate the falling blood pressure.

10. If the pulse is extremely weak, injection atropine is given intravenously, 0.6 mg of atropine is diluted in 5 ml of distilled water and is injected slowly till the radial pulse becomes palpable.

11. Broad spectrum antibiotics through the intravenous route are given.

12. The role of vasoconstrictor drugs is not valued in haemorrhagic shock however in neurogenic, anaphylactic and septicaemic shock injection adrenaline is helpful in raising blood pressure of the patient.

13. A potent painkiller like narcotic analgesic should be given to gan absolute relief from pain. However narcotics are not recommended respiratory distress and head injury.

ALLERGIC REACTIONS-

Allergy or hypersensitivity is unwanted response of the body to a complete dose of the drug. It is as a result an of an immunological response by the individual who has become sensitized to the drug through a prior exposure. It is an antigen antibody reaction where the drugs behave as antigens by joining with tissue proteins or polypeptides.

Allergic reactions can be immediate or humoral and delayed or cellular type. The cellular type allergy is due to the direct reaction of T-lymphocytes from the thymus gland with the antigen. The humoral or immediate allergic reaction is a result of serum antibodies or immunoglobulins produced by B-lymphocytes from the bone marrow. For anaphylaxis to develop, an initial exposure to an antigen is necessary. to produce specific antibodies which in turn. attach themselves to cell walls of the tissues, mast cells and circulating basophils. These sensitized antibodies are capable of initiating anaphylactic reaction on subsequent exposure to antigens. There is a release of chemical mediators like histamine bradykinin, prostaglandins, slow reacting substance of anaphylaxis (SRS-A) and platelet activity factors (PAF). These chemical mediators produce a series of reactions involving respiratory, cardiovascular, gastrointestinal, central nervous system and skin.

Allergic reactions may vary from skin reactions to anaphylaxis and the antigens commonly known to produce the reactions are penicillin and various other antibiotics, local anaesthetics especially ester type, preservatives in local anaesthetics, analgesics and the various medicaments used in dentistry.

Signs and symptoms

The allergic manifestations vary from skin reactions to anaphylaxis. It may be in the form of urticaria, erythema, maculo- papular or nodular rash, oedema of the skin and subcutaneous tissues or petechial haemorrhages. Similar lesions can also occur on the mucous membrane. There: may be angioneurotic oedema of the lips, tongue, eyelids, larynx and bronchi. A more severe reaction can lead to respiratory problems like dyspnoea,wheezing, bronchospasm, cyanosis or asphyxia. The histamine released can produce hypotension or even circulatory failure.

Management -

The shorter the time, more severe is the reaction. For cutaneous rashes, an oral antihistaminic or an intramuscular injection of chlorpheniramine maleate can be given. If the symptoms are severe an intravenous injection of 100 mg. of hydrocortisone sodium succinate or injection epinephrine 0.1 mg can be given subcutaneously.

Epinephrine is also drug of choice in bronchospasm alongwith administration of oxygen to support respiration. It should be followed by corticosteroids. In dire emergency tracheostomy should be performed. A true anaphylactic reaction with a sudden cardiovascular and respiratory collapse should be treated as follows

1 Make the patient lie down in supine (shock) position.

2. Maintain patent airway.

3. Administer 100% oxygen.

4. Administer injection epinephrine 1:1000, (0.5 mg) i.m. It should be given if the blood pressure falls below 60 mm of Hg and acute angioneurotic edema is establishing.

5. Start Intravenous infusion immediately.

6. Monitor pulse, blood pressure and respiration.

7 Administer hydrocortisone 100 mg) intravenously.

8 Administer antihistamines ( Benadryl 50 mg i. v).

9. Send the call for the physician for medical consultation and arrange for hospitalization.

RESPIRATORY EMERGENCIES

Emergencies involving respiratory system may become life threatening if prompt resuscitation measures are not taken .Following are the respiratory emergencies that need to be discussed.

HYPERVENTILATION

It denotes increase in alveolar ventilation disturbing the optimum levels oxygen and carbon dioxide. It is caused abnormally rapid and deep breathing leading to respiratory alkalosis.

Hyperventilation syndrome in a dental office is often precipitated by anxiety, fear, nervousness and emotional stress in a hysterical form at the conscious level. It is more commonly seen in females than males.

Signs and symptoms

Hyperventilation syndrome s recognised by dizziness and difficulty breathing, palpitation, tightness and mild pain in the chest may be seen. Numbness and tingling sensation of finger tips toes followed by carpopedal spasms of tetany, mental confusion, headache, fatigue and loss of consciousness.

Treatment

The problem can be prevented is reducing anxiety and fear. The treatment consists of instructing the patient to breathe slowly and deeply into a paper bag at the rate of

approximately ten times per minute.

Alternatively, the patient can be asked to old breath for sometime to reverse the respiratory alkalosis. These patients are difficult to command and the emergency

can be averted by closing the mouth and nostrils by placing a hand to bring the respiration rate down.

AIRWAY OBSTRUCTION BY FOREIGN BODY

Aspiration of foreign body may cause airway obstruction by occluding the air passages posing serious problems like bronchospasm and asphyxia. A complete respiratory obstruction is a serious complication that requires an immediate attention. The other causes of airway obstruction are swelling in the neck due to tumours, trauma or infection, tongue falling back in fractured and collapsed mandible or unconscious patients. It can be due to food, tooth, partial denture, blood clots, tenacious mucus, saliva or oral surgical instruments slipping into to the air passages. The obstruction can be complete or partial and hence the degree of blockade of airway .If the foreign body happens to be small causing partial obstruction at the level oropharynx, it is normally coughed out bythe patient but a complete obstruction by a large foreign body needs an immediate attention because it can lead to serious implications like dyspnoea and loss of consciousness.

Signs and symptoms

Teeth and removable partial dentures the most common foreign bodies that are displaced into the oropharynx, larynx, trachea and oesophagus. If the foreign body is displaced into the oropharynx it can either be swallowed down to the oesophagus, coughed out as a result of laryngeal irritation or passed into the respiratory passages. When the foreign body passes down the passages, patient may cough vigorously. There may be gagging, choking or wheezing in order to dislodge and eject out the foreign body. In case of partial obstruction, when the symptoms are mild, X-ray chest and abdomen is advised. The patients with foreign body in trachea or bronchi are referred for an immediate removal. If the obstruction is complete, the patient may gasp for breath. There is retraction of supra sternal and intercostal skin and muscles. Patient is unable to speak. The exchange of gases cannot be demonstrated either by feeling with back of the hand in front of the mouth and nose or by listening with ear and the patient is developing cyanosis fast. In case the tooth is lost into posterior portion of the mouth and no respiratory symptoms are seen, in majority of the cases the patient swallows the tooth into the oesophagus and it can be confirmed with radiograph.

Treatment

Treatment of airway obstruction is to be instituted as soon as the diagnosis is established that the foreign body has got lost in the respiratory passages Patient reflexly starts coughing out to dislodge the foreign body and expel it out. It can be further assisted by leaning the patient overthe chair and firmly patting at the back. Small children can be held upside down from the legs and gentle blows over the back are given.

If the treatment does not help, the patient is made to lie down in dental chair or on floor with head tilted to one side, Index finger and middle finger are pushed deep down the throat to grasp any object obstructing the airway in oropharynx or atleast dislodge the object to be expelled by the patient with a forceful cough.

In case the above treatment is not fruitful Heimlich procedure of expelling the residual air in lungs and respiratory passages by forceful external compression of the lungs to blow out the foriegn body is carried out. A sitting or standing patient is grasped from the waist area by standing at his back and a forceful upward thrust exerted. Alternatively in a lying down patient pressure is applied on the abdomen in an upward directions at a level above the navel and below the ribcage.

In case a laryngoscope, suction apparatus and Magill forceps are available these can be made use of for removal of foreign body. A fibroptic laryngoscope is the best help in the hands of an experienced laryngologist especially if an object has been pushed down to larynx.

In case the patient is developing bronchospasm and obstruction is incomplete, 100% oxygen should be given and surgical intervention is required as emergency treatment of such partial or complete obstructions. An emergency tracheotomy or tracheostomy is required to be performed

Tracheotomy or cricothyroidotomy

The cricothyroid membrane area is palpated as a triangular area between the thyroid cartilage above and cricoid cartilage gauge inferiorly. It can be punctured with the help of scalpel, no. 18 needle or specially designed trocar. The overlying skin and membrane straightway punctured. Cricothyroid tube through or cannula directed downwards is secured in position to maintain the airway through which oxygen can be administered.

Tracheostomy

A sand bag is placed under the shoulders of the patient to extend the neck. A midline or transverse skin incision is made in the skin and plstysma over the third tracheal ring. Two or three tracheal rings are exposed after separating the pretracheal muscles. Window is made on the trachea by splitting the tracheal ring. Opening is dilated with tracheotomy dilator and tracheostomy tube is inserted into the trachea. A sterilized gauze piece is kept on the mouth of the tube to prevent inhalation of any fly or mosquito and dust. The tube is secured in place with ribbon tape tied around the neck. Oxygen can be administered through the tube. Slight bleeding encountered during the procedure should be removed with suction apparatus and no blood is allowed to trickle down the bronchial tree.

The obstruction caused by foreign bodies can be prevented by always packing the throat with gauge etc. and use of cuffed tubes while working under general anaesthesia. For endodontic and conservative dentistry procedures rubber dam should always be applied Firmly grip the teeth etc. during extraction procedures.

BRONCHOSPASM

Bronchitis and Bronchial Asthma

Patients with a history of bronchial asthma may develop acute bronchospasm. It may be triggered by emotional stress and anxiety during the course of treatment. Asthma is of two types

It may be due to emotional stress as a response to infection or it can be because of bronchonasal allergy to irritants like pollens, dust, foods, feathers etc. There is bronchospasm involving generalised contractions of smooth muscles of the bronchial tree. In an asthmatic attack. bronchospasm leads to airflow obstruction which is aggravated by oedema of the lining as well as collection of secretions in the bronchioles giving a radiological picture of consolidation.

The asthmatic attack can be mild with lew symptoms or status asthmaticus which is a life threatening emergency. There is dyspnoea or orthopnoea, wheezing is a prominent sign which means forced respiration due to bronchial narrowing. Wheezing is localized in bronchial obstruction. Patient frequently coughs to 8 Fluid replacement by intravenous or clear the mucus from the bronchial tree. The patient gives an expression of anxiety.

There is shortness of breath, wheezing and tightness in the chest. As the attack prolongs symptoms of fatigue, restlessness and itability appear. It may be accompanied by cyanosis with the accessory muscles showing laboured breathing along with suprasternal and intercostal retraction.

Management

1 Patent is allowed to sit down in a reclining posture.

2. 100% Oxygen is administered if cyanosis has established. Otherwise. 20-30% Oxygen is extremely useful.

3. These patients usually carry their own medicines in their pockets in the form of inhalers containing bronchodilators and steroids. These should be tried to stop the attack and clear bronchospasm.

4 In case the inhalers do not help, injection aminophylline 5-6 mg/kg body weight should be given intravenously, slowly.

5. Steroids like hydrocortisone hemisuccinate or dexamethasone may be given intravenously as life saving drug. These do help as stress bearing factors of the body.

6. Injection of adrenaline 0.3 mg (1:1000 dilution) is given subcutaneously in status asthmaticus.

7. Mucolytic agents like bromehexine alongwith steam inhalation and cover of antibiotics etc are important in the management. However, use of narcotics should be avoided.

8 fluid replacement by intravenous or oral route should be done. 

9. Any known allergens like pollens, flowers, dust, feathers in pillows etc should be eliminated from the surroundings and stress should be kept minimum. However, heavy sedation should not be given.

HYPERTENSION

When a patient exhibits blood pressure above 160/100 mmHg in the pre operative phase, he is labelled as hypertensive.

Such patients can pose problems involving heart, brain and kidneys .Cardiovascular problems like angina pectoris, infarction or congestive heart failure and cerebrovascular problems like stroke or cerebro- vascular accidents. In a milder form, hypertensive patients can pose problems of excessive Intra-operative bleeding Patients may complain of headache, dizziness, nausea and even vomiting whenever the blood pressure rises above 160/100 mmHg.

Fundus examination reveals haemorrhages or exhibits blood spots over the retina with increased intracranial tension.

The stress of surgery or long wait prior to surgery, exertion etc. can cause hypertension. This can be avoided by proper pre-medication. Should this emergency arise intra-operatively, the patient is allowed to take rest a semi-sitting position. Oxygen may be administered to bring down the blood pressure. If it does not help, a small amount of injection diazepam may be administered intravenously at a very slow rate. This normally settles the stress related hypertension. it is not helpful, the patient should be left to the care of medical specialist. In the mean time, injection Frusemide (Lasix) is given intravenously and the i.v. line is maintained as a preparation to any serious emergency. A 10 mg capsule of Nifedipine may be broken and sprinkled sublingually to bring the blood pressure down.

Other complications like angina pectoris or stroke should be kept in mind and immediately handled in case these develop.

HYPOTENSION

A fall in blood pressure or hypotension during oral surgical procedures can be due to a simple common fainting attack. However, more serious complications like shock, adrenal crisis and hypoglycaemia etc. lead to hypotension and are serious emergencies. The systolic blood pressure that was previously normal if drops below 80 mm of Hg denotes hypotension. There is associated weak pulse and bradycardia Patient exhibits restlessness, confusion, nausea and stupor.

Management

1 Put the patient in supine position with legs raised. Patients with cardiac ailment should be placed in semi sitting position whereas females in advanced stage of pregnancy are made to lie down on their side.

2. 100% oxygen should be administered .

3. IV. line should immediately be maintained with Ringer lactate solution.

4. Atropine 0.6 mg diluted in 5 ml of sterile water is given intravenously slowly if the pulse is less than 60 per minute. Atropine should be stopped when a good volume radial pulse with a rate of 72 per minute appears.

5 Injection mephentermine 15 mg can be administered intravenously or intramuscularly. At times phenylepherine 2mg subcutaneously is also recommended.

6. Corticosteroids like hydrocortisone sodium succinate 100 mg should be administered intravenously combating stress.

ISCHAEMIC HEART DISEASE-

It denotes ischaemia of myocardium due to atherosclerosis of the coronary arteries leading to arrhythmias, angina pectoris, myocardial infarction or sudden death. The problem may be precipitated and diagnosed in the dental chair during some procedure.

Alternatively, these patients are at an increased risk during oral surgical procedures and may pose with serious emergencies.

The condition is characterised by tightness in the chest, sensation of choking and a referred pain in the left arm and shoulder. The pain may be referred to the jaw and neck. The attack may be precipitated on exertion, emotional stress etc. and is controlled with one or two tablets of nitroglycerine kept sublingually The pain is more severe and prolonged in myocardial infarction. The portion of the heart muscle distal to occlusion of coronary artery develops a typical type of necrosis in which the muscle looses its property of contraction.

In case an attack of angina pectoris occurs in dental chair, the dental treatment should immediately be stopped, adjust the chair in semi- reclining position. A tablet of nitroglycerine is placed sublingually and can be repeated after five minutes. Oxygen should be administered. In case two tablets of nitroglycerine fail to control the pain, the diagnosis of angina pectoris should be reviewed.

The patient's physician should be immediately called. In case of myocardial infarction, pain may be controlled with myocardial small amounts of morphine. Injection atropine should be given if there is bradycardia. Injection Mephentermine administered for control of hypotension. In a patient reporting with a recent history of myocardial infarction. any elective surgery should not be undertaken for a period of 6 months.

TACHYCARDIA AND ARRHYTHMIAS

Abnormally fast heart rate (tachycardia) or irregular beats and missing beats (arrhythmias) are conditions that may lead to an emergency in the dental office. A paroxysmal atrial tachycardia can be precipitated in the dental chair due to fear psychosis or pain by the prick of the needle as well as due to vasoconstrictor in the anaesthetic solution. Tachycardia and arrhythmias are also observed following exertion, excitement or nervousness. The patient complains of palpitation. perspiration and dyspnoea. When the heart rate is more than 200 beats/min, radial pulse may feel weak. The blood pressure falls down and clinical stasis in blood flow may develop leading to cerebral ischaemia and fainting Should such an attack develop in the dental chair, further dental treatment should be discontinued. Patient should be reassured time and again. Few sips of chilled water normally help to control an attack of paroxysmal atrial tachycardia by vagal stimulation. It can also be accomplished by pressing on the eye balls with eye closed, trying forceful expiration with mouth and nostrils closed. In case it. does not help. pressure on the carotid artery may be exerted with thumb by pressing unilaterally against the hyoid bone. A bilateral compression can lead to asphyxia or cardiac arrest. An injection of isoptin (verapamil hydrochloride) or diazepam given slowly intravenously can control the attack. Care must be exercised during administration of medicines as these patients are normally on adrenergic antagonists and beta blockers. If cyanosis develops oxygen should be administered. The patient should be put into the care of medical consultant to evaluate the underlying cause and treatment.

CONGESTIVE HEART FAILURE

Heart failure may be defined as inability of the heart to pump sufficient amount of blood in circulation and to body tissues to meet the demand of oxygenation at cellular level. Left heart failure following myocardial infarction produces dyspnoea, chronic cough and bronchospasm. Patient gets up at night as a result of paroxysmal nocturnal dyspnoea. It is because the left ventricle cannot pump efficiently the blood received from the left atrium. This in turn creates a back pressure producing pulmonary oedema and interference in gaseous exchange leading to dyspnoea. Patient exhibits pulsus alterans that means a regular rhythm with alternating strong and weak beats of pulse. The right heart failure produces venous congestion and increased jugular venous distension, peripheral oedema and hepatomegaly. Patients of heart failure complain of fatigue, breathlessness and chest congestion. There may be tachycardia, a third heart sound on auscultation and compensatory cardiac enlargement in the radiographs. These patients need careful handling under the expert guidance of medical should be treated specialist after proper management. Patient is advised complete bed rest and feels more comfortable when the head side of the bed is raised. Salt restricted diet helps in the management of the fluid retention. Additionally diuretics are advised and heart is digitalised. If the patient develops acute pulmonary oedema in the dental office, he/she is made comfortable in a sitting or semisitting position. 100% oxygen is administered, Inj Frusemide may be administered as diuretic and aminophylline for clearing the bronchospasm.

CARDIO-PULMONARY ARREST

There is sudden arrest of ventilation and circulation. It may occur in patients with already existing cardiovascular disease, anaphylaxis, toxic reaction of medicines, asphyxia etc. Clinically, it is characterised by absence of chest and abdominal movements, breath sounds, carotid and femoral pulse. The patient is unconscious with dilated pupils.

The management includes immediate cardio-pulmonary resuscitation because delay in reviving the patient beyond a time period of 3 minutes will result in irreversible brain damage.

Maintenance of a patent airway, continuous breathing and circulation are of utmost importance .The neck should be ended and the mandible is forced forward to lift the tongue away from the posterior pharyngeal wall. If the patient has not resumed breathing, artificial breathing to be started immediately. It can be a accomplished with the help of a mask attached to anaesthetic machine or ambubag ,It is advisable to intubate the patient to keep the patency of airway. If these facilities do not exist, a mouth to mouth or mouth to nose ventilation at the rate of 12 per minute should be given. In an adult supplemental oxygen should be used as soon as possible to avoid metabolic acidosis.

DIABETIC EMERGENCIES

There are two types of problems  associated with diabetics getting treatment in a dental office

1 Hypoglycaemia or insulin shock.

2 Diabetic coma or ketoacidosis or hyperglycaemia

Hypoglycaemia is seen more frequently and is usually seen when the patient has inadequate intake of food following his usual dose of insulin or oral hypoglycaemic agent. The hyperglycaemia is seen when the patient omits his dose of insulin and remains ill for a few days.

Signs and symptoms

Hypoglycaemia is represented by pallor, sweating and tremors. There is palpitation, generalised weakness and the hunger pains. Patient may exhibit symptoms like tachycardia, headache, confusion, visual disturbances and disturbances of speech. Ultimately coma may develop. The known diabetics can judge the condition by themselves and help themselves by consuming small quantities of glucose.

The characteristic features of hyperglycaemia are dry skin and hypotension. There is dry skin and a history of polydipsia, polyurea and polyphagia. Patient has typical acetone breath with a rapid deep breathing. Patient looks ill, dehydrated with dry skin, dry mouth and enophthalmos. Ultimately diabetic coma may develop after a few days of illness.

Management

In a conscious patient hypoglycaemia is managed by administering 20 gm of oral glucose. In an unconscious patient. parenteral administration of dextrose solution gives immediate relief. The hyperglycaemia or acidosis needs administration of insulin and fluids alongwith electrolyte monitoring be done in a hospital under the care of physician.

EPILEPSY

This is a central nervous system disturbance involving convulsions followed by loss of consciousness. Majority of the patients are conscious of their problem and should be warned about the importance of medicine which is generally recommended on long term basis. An emergency can arise in the dental office when the epileptic seizures occur during treatment. When two or more major seizures occur in succession, it is labelled as status epilepticus and it is a serious emergency. Convulsions can also be seen in high grade fever, brain tumour, head injury, hypoglycaemia, hypocalcaemia and drug toxicity. Therefore, a careful history prior to surgery is important. Rarely in an epileptic, intravenous sedation may be required in the dental office. The airway should be kept patent during an epileptic fit. Crush injury to the tongue should be avoided by holding a blunt object between the teeth.

ADRENAL INSUFFICIENCY

Patients who are on long term corticosteroid for the treatment of the systemic conditions develop adrenal suppression. If any such patient is under stress emotionally or otherwise adrenal suppression prevents the normal release of gluco-corticoids from adrenal cortex and such a a patient not be able to respond normally to a stress. It is because of fall in the production of ACTH the (adreno -corticotrophic hormone) secreted by anterior pituitary in response to the administered to the patient. ACTH in turn controls the production of the corticoids in the adrenal cortex.

The symptoms of adrenal crisis are anxiety, fatigue, hypotension,abdominal pain, nausea and vomiting, cold clammy skin, lethargy and partial or complete loss of consciousness. The attack is triggered by accident, pain, anxiety, infection and surgery.

Further dental treatment should be stopped.Put the patient in shock position. Maintain patency of the airway and administer oxygen. Send the call for the physician, start i.v. line with 5% dextrose saline. Administer 100-200 mg of hydrocortisone sodium succinate intravenously.

Prevention is always better in such patients. A careful history should be taken and if the patient has been or is using steroids on long term basis, the problems of adrenal crisis should be considered.

PREGNANCY

There are not much problems associated with treatment in the dental office as regards to pregnant mothers. However, the stress and strain involved can lead to complications during the treatment. The physiological changes occuring in the body during pregnancy lead to an exaggerated response to stress. There are various hormonal changes during the progress of this condition leading to an increase in the blood volume, cardiac output, glomerular filtration rate and oxygen requirement etc.

During the first trimester, there may be persistent vomiting and morning sickness due to carbohydrate starvation and ketosis During the last trimester, the position of the patient in the dental chair is very important. A patient in supine or reclined position can have pressure on inferior vena cava by the foetus leading to poor venous return and subsequent hypotension. Turning the patient on to the left side will relieve the pressure and put the patient back to the normal. The foetus is highly sensitive and hence vulnerable: to environmental influences. especially between 3rd- 10th week of intrauterine life. It susceptible to develop is malformations if the mother passes through stress and strain. So, all planned surgical procedures should be avoided during the first trimester to avoid foetal stress and during the third trimester to avoid premature labour.

CEREBROVASCULAR ACCIDENTS

CVA or stroke is a very serious problem that can occur in a dental office There is either haemorrhage or thrombosis resulting in focal brain damage. Patients with uncontrolled, untreated hypertension older individuals with atherosclerosis patients with vascular malformations and haematological disorders are more prone to stroke.

The signs and symptoms depend on the focus of injury and extent of damage to the brain. Patient may exhibit weakness visual disturbances, speech problems, hemiplegia and unconsciousness. The patients at risk should be carefully handled with detailed history and proper premedication should be used. If this emergency arises in the dental. office patient should be shifted to the care of medical specialist in a comfortable position. If hypertension or haemorrhage is the causative factor, the head should be kept raised. Patency of the airway should be maintained and administer oxygen in case of respiratory difficulty Antihypertensive drugs are recommended and i.v. line with slow administration of 5% dextrose is maintained for the administration of emergency medicine.