Medical Emergencies in Dental Practice www.ajlobby.com www.ajlobby.com Medical Emergencies in Dental Practice Orrett E Ogle, dds Lecturer, Mona Dental Program Faculty of Medicine University of the West Indies Kingston, Jamaica Former Chief of Oral and Maxillofacial Surgery Woodhull Medical Center Brooklyn, New York Harry Dym, dds Chairman Department of Dentistry and Oral and Maxillofacial Surgery The Brooklyn Hospital Center Brooklyn, New York Clinical Professor Department of Oral and Maxillofacial Surgery Columbia University College of Dental Medicine New York, New York Robert J Weinstock, dds Private Practice Limited to Oral and Maxillofacial Surgery Guilford, Connecticut Clinical Instructor Oral and Maxillofacial Surgery Yale-New Haven Hospital New Haven, Connecticut Quintessence Publishing Co, Inc Chicago, Berlin, Tokyo, London, Paris, Milan, Barcelona, Istanbul, Moscow, New Delhi, Prague, São Paulo, Seoul, and Warsaw www.ajlobby.com Library of Congress Cataloging-in-Publication Data Names: Ogle, Orrett E., editor | Dym, H (Harry), 1938- , editor | Weinstock, Robert J Title: Medical emergencies in dental practice / [edited by] Orrett E Ogle, Harry Dym, Robert J Weinstock Other titles: Medical emergencies in dental practice (Ogle) Description: Hanover Park, IL : Quintessence Publishing Co, Inc., [2016] | Includes bibliographical references Identifiers: LCCN 2015038602 | ISBN 9780867155693 Subjects: | MESH: Dentistry | Emergency Treatment methods | Critical Care methods | Emergencies Classification: LCC RK51.5 | NLM WU 105 | DDC 617.6/026 dc23 LC record available at http://lccn.loc.gov/2015038602 The authors and the publisher of this work have made every effort to provide reliable information that can be used to aid treatment in emergency situations However, emergencies, by their nature, are unpredictable and involve diverse variables Furthermore, changes in treatment technique and medical protocol evolve with new developments in research and clinical experience Thus, readers are encouraged to confirm the information contained herein with other sources, and they are advised to be aware of all pertinent governmental regulations and to review relevant manufacturer information prior to use of a product Finally, it is the responsibility of practitioners to use their best judgment and clinical expertise when treating their patients Neither the authors nor the publisher of this work guarantees that the information contained herein is in every respect accurate or complete © 2016 Quintessence Publishing Co, Inc Quintessence Publishing Co Inc 4350 Chandler Drive Hanover Park, IL 60133 www.quintpub.com All rights reserved This book or any part thereof may not be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, or otherwise, without prior written permission of the publisher Editor: Bryn Grisham Design: Ted Pereda Production: Kaye Clemens Printed in the USA www.ajlobby.com Contents Preface  vii Contributors  ix Pretreatment Evaluation of the Dental Patient 1 Essentials of an Emergency Kit 9 Respiratory Emergencies 15 Acute Chest Pain 27 Syncope 44 Allergy and Anaphylaxis 51 Seizures, Epilepsy, and Stroke 69 Nausea and Vomiting 77 Hemorrhagic Emergencies 85 10 Emergencies in the Pregnant Dental Patient 103 11 Hypertension and Hypotension 112 www.ajlobby.com 12 13 14 15 16 17 18 TMJ Emergencies 119 Diabetic Emergencies 125 Malignant Hyperthermia 133 Thyroid Crisis 140 Local Anesthesia Emergencies 147 Adrenal Crisis 156 Basic Life Support 164 Index  177 www.ajlobby.com Preface It is imperative that every dentist in clinical practice be prepared to manage medical emergencies that may arise during patient treatment It is true that clinicians can prevent many emergencies by conducting a thorough medical history, making appropriate alterations to dental treatment as required, and optimally stabilizing the patient’s medical condition when possible However, despite all efforts at prevention, emergencies will occur It is therefore necessary that dentists have a sound knowledge base as to how to manage medical emergencies that they may encounter The ability to initiate effective primary management is the key to minimizing morbidity and mortality In general, medical emergencies in dental practice are perceived as infrequent, but when an emergency does occur, it can be life threatening, so the dental staff must be prepared The prevalence of medical emergencies in dental offices is unknown Estimates of the frequency vary widely One report estimated that sudden cardiac arrest occurs in in 638, 960 patients while at a dental facility and that a severe life-threatening event occurs in in 30,427 treated patients.1 Another report from the State University of New York at Buffalo College of Dentistry found the incidence of emergencies to be 164 events per million patient visits.2 A third study reported a frequency of emergency in 3.6 to 4.5 practice years.3 The American Dental Association4 has estimated that there are about 3,000 life-threatening medical emergencies a year in US dental offices The best way to ensure effective management of a medical emergency is to be prepared in advance During a medical emergency, the dentist is legally responsible for keeping the patient alive until his or her condition improves or until the patient can be transported to a facility with a higher level of care If the practice is in an isolated area, or a location that is difficult to access (for example, because of heavy traffic or slow elevators), the dentist will be responsible for the patient for a longer period of time The aim of this book is to arm clinicians with information that will prepare them to effectively manage various medical emergencies From the beginning, we created this book with the busy clinician in mind It was our goal to produce a reference text that would be easy to read and understand and would present effective emergency management in a succinct, organized sequence Beneficial step-by-step treatment guidelines and algorithms outline the steps and decision-making process for each emergency medical situation In addition, we identified contributors with significant experience dealing with medical emergencies as hospital-based dental practitioners Each chapter focuses on a distinct physiologic system and the common related emergencies that practitioners may encounter We think this book will be an ideal clinical reference because it is accessible and presents a systematic approach of how to manage specific medical emergencies vii www.ajlobby.com We recommend that clinicians read through the entire book to familiarize themselves with management of common medical emergencies Because emergencies are, by definition, unpredictable events that can happen to anyone at any time, the dental practitioner and office staff must be prepared to provide primary management for any medical emergency without first turning to a book Familiarity with common medical emergencies is therefore crucial Practitioners are also encouraged to review the contents of their emergency kits and become knowledgeable about the pharmacology and use of the key drugs that should be maintained in the kit As editors, we are very enthusiastic about this book and the information it presents We hope you will find this text to be very useful in your clinical practice References 1.  Müller MP, Häansel M, Stehr SN, et al A state-wide survey of medical emergency management in dental practices: Incidence of emergencies and training experience Emerg Med J 2008; 25:296–300 2.  Anders PL, Comeau RL, Hatton M, Neiders ME The nature and frequency of medical emergencies among patients in a dental school setting J Dent Educ 2010;74:392–396 3.  Atherton GJ, McCaul JA, Williams SA Medical emergencies in general dental practice in Great Britain Part 1: Their prevalence over a 10-year period Br Dent J 1999;186:72–79 4.  Be Prepared: Medical Emergencies in the Dental Office DentalCompare Available at: http://www dentalcompare.com/Featured-Articles/2225-Be-Prepared-Medical-Emergencies-in-the-Dental-Office/ Accessed 13 October 2015 Acknowledgments This book is the brainchild of Dr Harry Dym and Lisa Bywaters, director of publications at Quintessence Publishing, who saw a need for an updated text on medical emergencies in dental practice We are grateful for their foresight and cannot thank Lisa Bywaters enough for initiating this project and standing by it despite the obstacles along the way Special thanks is also due to senior editor Bryn Grisham, who spent nearly years diligently working with us and providing encouragement and valuable advice Credit is also due to Kaye Clemens for her production work and excellent assistance with our images and photographs, which were not always the best We also thank all of the contributors who gave of their time and shared their knowledge Finally, we most especially thank our family members from whom we took valuable time to work on this book viii www.ajlobby.com Contributors Ida Anjomshoaa, dmd Chief Resident Division of Oral and Maxillofacial Surgery The Brooklyn Hospital Center Brooklyn, New York Harry Dym, dds Resident Division of Oral and Maxillofacial Surgery The Brooklyn Hospital Center Brooklyn, New York Chairman Department of Dentistry and Oral and Maxillofacial Surgery The Brooklyn Hospital Center Brooklyn, New York Clinical Professor Department of Oral and Maxillofacial Surgery Columbia University College of Dental Medicine New York, New York George Blakey, dds Roger I Grannum, dds Golaleh Barzani, dmd Director of Oral and Maxillofacial Surgery Residency Program Distinguished Associate Professor Department of Oral and Maxillofacial Surgery School of Dentistry University of North Carolina Chapel Hill, North Carolina Carolyn Dicus Brookes, md, dmd Assistant Professor Department of Otolaryngology and Communication Services Division of Maxillofacial Surgery Medical College of Wisconsin Milwaukee, Wisconsin Earl Clarkson, dds Director Division of Oral and Maxillofacial Surgery Woodhull Medical Center Brooklyn, New York Division of Oral and Maxillofacial Surgery Woodhull Medical Center Brooklyn, New York Leslie Robin Halpern, md, dds, phd, mph Associate Professor and Program Director Department of Oral and Maxillofacial Surgery Meharry Medical College School of Dentistry Nashville, Tennessee Curtis Holmes, dds Chief Resident Division of Oral and Maxillofacial Surgery The Brooklyn Hospital Center Brooklyn, New York Ghazal Mahjoubi, dmd Private Practice Limited to Oral and Maxillofacial Surgery New York, New York ix www.ajlobby.com 18 BASIC LIFE SUPPORT 13.  Morettia MA, Machado Cesar LA, Nusbacher A, Kern KB, Timerman S, Franchini Ramires JA Advanced cardiac life support training improves long-term survival from in-hospital cardiac arrest Resuscitation 2007;72:458–465 14.  Sinz E, Navarro K, Soderberg ES, Callaway CW (eds) Advanced Cardiovascular Life Support: Provider Manual Dallas TX: American Heart Association, 2011:54 15.  Balady GJ, Chaitman B, Foster C, Forelicher E, Gordon N, Van Camp S AHA/ACSM scientific statement automated external defibrillators in health/ fitness facilities: Supplement to the AHA/ACSM recommendations for cardiovascular screening, staffing, and emergency policies at health/fitness facilities Circulation 2002;105:1147–1150 176 16.  Abella BS, Aufderheide TP, Eigel B, et al Reducing barriers for implementation of bystander-initiated cardiopulmonary resuscitation: A scientific statement from the American Heart Association for healthcare providers, policymakers, and community leaders regarding the effectiveness of cardiopulmonary resuscitation Circulation 2008;117:704–709 Index Page numbers followed by “f ” indicate figures; those followed by “t” indicate tables; those followed by “b” indicate boxes A Absence seizures, 70–71 Absorbable gelatin sponges, 90, 91t, 92f Acetaminophen, 144 ACLS See Advanced cardiac life support ACS See Acute coronary syndrome ACTH See Adrenocorticotropic hormone Acute asthmatic attack, 20, 21b, 21f, 109 Acute blood loss, 94, 95f Acute chest pain See Chest pain, acute Acute closed lock, 122b, 122–124, 123f Acute coronary syndrome atherosclerosis and, 29–30 chest pain caused by, 27–33 components of, 29 emergency response to, 39–41, 41f non-ST-elevation myocardial infarction, 29, 31–32, 40 oxygen supplementation for, 40–41 physical examination of, 33, 34f signs and symptoms of, 31b–32b ST-elevation myocardial infarction, 29, 31–32 unstable angina, 29, 31, 40 Acute hypotension, 116, 117f Acute systemic anaphylaxis, 52 Acute vomiting, 80, 81f Addison disease, 157, 160 Adrenal crisis adrenal insufficiency progression to, 162 cortisol intake and, 159 definition of, 156, 160 dexamethasone for, 161–162 emergency management of, 161f, 161–162 signs and symptoms of, 160, 161b Adrenal glands anatomy of, 156, 157f steroid hormones produced by, 156–157 Adrenal insufficiency, 14t adrenal crisis progression of, 162 clinical features of, 158 definition of, 156 dental management of, 159–160 manifestations of, 158 prevalence of, 157–158 primary, 157–158, 158b, 158t secondary, 158, 158b, 158t steroid supplementation for, 159, 159b tertiary, 158, 158b treatment of, 158–159 types of, 157–158 Adrenocorticotropic hormone, 157–158 Advanced cardiac life support basic life support and, 172 description of, 172 local anesthetic overdose managed with, 150, 151b training in, 165, 172 AED See Automated external defibrillator Airway artificial, 10, 10f in basic life support, 167–168, 170b in children, 170b Airway obstruction anesthesia-related, 22, 23f foreign body as cause of, 16f–18f, 16–17 sedation-related, 22, 23f Albuterol asthma treated with, 22 bronchospasm treated with, 26 description of, 12 Aldosterone, 157 177 I A  Index Allergic reactions See also Anaphylactoid reaction; Anaphylaxis anaphylactoid reaction versus, 52–53 angioedema, 54 dermatitis, 54 Gell-Coombs classification of, 52, 52f, 66 to latex, 58 lesions caused by, 53–54 to local anesthetics, 153 mild, 60–61, 62f, 64 prevalence of, 51 prevention of, 65–66 signs and symptoms of, 53–54, 54f Allergies contact, 54 emergency treatment of, 13t food, 59 management of, 60–65, 61b preoperative evaluation of, 6t shellfish, 59 symptoms of, 13t testing for, 66 American Society of Anesthesiologists physical status classification, 5, 5f Amide local anesthetics, 148 Ammonia, aromatic, 12, 12f Anaphylactic reactions to benzodiazepines, 57 to local anesthetics, 57 to muscle relaxants, 58 non–drug-induced, 59 to opioids, 57–58 Anaphylactoid reaction allergic reactions versus, 52–53 anaphylaxis versus, 55, 55f antihistamines for, 64, 64t atropine for, 65 ß-blocker antagonists for, 64t, 64–65 components of, 61 corticosteroids for, 64, 64t definition of, 51 epinephrine for, 63–64, 64t management of, 61–65, 63f oxygen therapy for, 62–63 signs and symptoms of, 54–60 vasopressors for, 65 178 Anaphylaxis See also Allergic reactions acute systemic, 52 anaphylactoid reaction versus, 55, 55f biphasic, 59–60 clinical presentation of, 60 components of, 61 definition of, 51 drug-induced, 55–59 emergency treatment of, 13t etiology of, 52–53 food as cause of, 59 immunogenesis of, 52–53 immunoglobulin E-mediated, 54 to latex, 58 management of algorithm for, 63f antihistamines, 64, 64t atropine, 65 ß-blocker antagonists, 64t, 64–65 corticosteroids, 64, 64t epinephrine, 63–64, 64t equipment and supplies for, 61b oxygen therapy, 62–63 vasopressors, 65 volume resuscitation, 65 mediators of, 52–53 to opioids, 57–58 perianesthetic See Perianesthetic anaphylaxis prevention of, 65–66 signs and symptoms of, 13t, 51 summary of, 66 triggers of, 51 Androgens, 156 Anesthesia airway obstruction during, 22, 23f anaphylaxis caused by See Perianesthetic anaphylaxis aspiration during, 26 asthma prophylactic therapy before, 66 bronchospasm during, 24–26, 25f drug reactions during, 55 laryngospasm during, 22–24, 24b nausea and vomiting during, 77, 80, 82f respiratory emergencies during, 15, 22–26 Anesthetic agents local See Local anesthetics Index B in malignant hyperthermia-susceptible patients, 135b perianesthetic anaphylaxis caused by, 56t, 57–58 Angina pectoris See also Chest pain, acute classification of, 5f, 6t emergency treatment of, 13t nitroglycerin for, 12–13 stable, 30–31 symptoms of, 13t unstable, 29, 31, 40 Angioedema, 54 Antibiotics cephalosporins, 57 drug reactions to, 55–57 penicillin, 55–57 vancomycin, 57 Anticoagulants, 74 Antidepressants, for temporomandibular joint pain, 121, 122b Antihistamines anaphylaxis managed with, 64, 64t postoperative nausea and vomiting managed with, 82, 82f Antiplatelet medications, 99 Antipyretics, 144 Anxiety chest pain caused by, 38 coronary artery disease and, 38 severe, 45 signs of, 47b Aortic aneurysm enlargement/rupture, 35–36 Aortic dissection, 33–35, 34f–35f, 35b Aortic wall, 33, 34f Aortocaval compression syndrome, 116 Aromatic ammonia, 12, 12f Arrhythmias, cardiac, 48 Articaine with epinephrine, 148t Artificial airways, 10, 10f Aspiration foreign body, 16 pulmonary, 26 in sedated patients, 80 Aspiration pneumonitis, 26 Aspirin, 12, 74, 99 Asthma description of, 20b, 20–22, 21f emergency treatment of, 13t hospitalization referral for, 110b management of, 110f in pregnancy, 109, 110b, 110f preoperative evaluation of, 6t prophylactic therapy for, 66 symptoms of, 13t Asthmatic attacks, 20–21, 21b, 21f, 109 Atherosclerosis, 29–30 Atherothrombolic brain infarction, 74 Atrial fibrillation, 141, 142f, 144b, 145f, 145–146 Atropine, 65 Automated external defibrillator for use with adults, 166, 168 for use with children, 171, 174–175 definition of, 172 in dental office, 172–175 description of, 11, 38 for use with hairy chest patients, 173–174 illustration of, 11f, 172f for use with implanted defibrillator patients, 174 for use with infants, 174–175 need for, 175 pacemakers and, 174 pad placement for, 173f, 175 protocol for, 173, 174f shockable rhythms, 173 survival rates and, 175 transdermal medications and, 174 B Bag-valve-mask device for use with children, 171 description of, 12, 12f, 62–63 for use with laryngospasm patients, 24 steps for use, 168f Basic life support advanced cardiac life support and, 172 airway, 167–168 algorithm for, 166f assessment, 166–167, 167f 179 I B  Index automated external defibrillator use in, 166, 168–169 breathing, 167–168 cardiopulmonary resuscitation, 168 chest compressions, 166–167, 167b, 167f for children, 169–171, 170b–172b, 170f circulation-airway-breathing sequence of, 166– 167, 167b curricular guidelines for training in, 164 definition of, 164 local anesthetic overdose treated with, 150 mnemonic for steps involved in, 165, 165b office personnel training in, 165 overview of, 165 oxygen supplementation during, 167 regulatory requirements, 164 rescue breaths, 167b, 168 steps involved in, 165b summary of, 169b, 175 Benzocaine topical anesthetic, 79, 79f Benzodiazepines anaphylactic reactions to, 57 perianesthetic anaphylaxis caused by, 56t ß2-agonists bronchospasm treated with, 26 short-acting, 20b types of, 12 ß-blockers, 64t, 64–66 Biphasic anaphylaxis, 59–60 Bleeding See also Hemorrhagic emergencies bony, 86–87 in coagulation defect patients, 99–100 inferior alveolar neurovascular bundle, 88 intraoperative See Intraoperative bleeding management of, 89–93, 90f, 91t, 92f–93f nasal mucosa, 88–89, 89f nonsteroidal anti-inflammatory drugs as cause of, 85, 99 oral, 96–98, 97b, 97f–98f postextraction, 93–94 postoperative, 93–94, 100 preoperative screening for, 85 soft tissue, 86 tongue lacerations as cause of, 96, 97b, 97f–98f Blood glucose monitoring in diabetes, 127 180 hypoglycemia prevention through, 128 postsurgical, 131 Blood pressure determinants of, 112 formula for, 112, 113f high See Hypertension low See Hypotension Blood transfusion, 94–96, 95f–96f, 96t Blood volume normal, 95b in pregnancy, 104 BLS See Basic life support Bone wax, 91t, 92 Bony bleeding, 86–87 Breathing, 167–168 Bronchospasm, 24–26, 25f Bronchus, foreign body obstruction in, 16f Bupivacaine without epinephrine, 148t, 149 BVM device See Bag-valve-mask device C CAD See Coronary artery disease Calcium, intracellular, 134 Canadian Cardiovascular Society angina pectoris classification, 5f Carbon dioxide, 19–20 Cardiac arrest, 169 Cardiac arrhythmias, 48 Cardiac catheterization, 32 Cardiac output, 113f Cardiac stratification, 6t Cardioembolic stroke, 74 Cardiopulmonary resuscitation for adults, 168 for children, 169–171 Carotid endarterectomy, 74 Carotid sinus syncope, 47 Cautery See Electrocautery Cephalosporins, 57 Cerebrovascular disease, 6t Cerebrovascular syncope, 47f, 48 Cervical disc disease, 37–38 CHADS2/Vasc score, 145–146 Chemical cauterization, 93 Index C Chemotherapy, 78t Chest compressions for adults, 166–167, 167b, 167f for children, 169, 171b Chest pain, acute See also Angina pectoris assessment of, 38, 39f causes of acute coronary syndrome, 27–33 anxiety, 38 aortic aneurysm enlargement/rupture, 35–36 aortic dissection, 33–35, 34f–35f, 35b atherosclerosis, 29–30 cardiovascular, 37 gastrointestinal, 37 life-threatening, 29–36 musculoskeletal, 37–38 non–life-threatening, 37–38 non-ST-elevation myocardial infarction, 29, 31–32, 40 psychologic, 38 pulmonary, 37 pulmonary embolism, 36 stable angina, 30–31 ST-elevation myocardial infarction, 29, 31–32 unstable angina, 29, 31, 40 differential diagnosis of, 28f, 28–29 emergency response to, 39–41, 41f history-taking, 38–39 management of, 38–39, 39f physical examination of, 39 prevalence of, 27 prevention of, 27, 28f symptoms of, 29b Children airway in, 170b automated external defibrillator for, 174–175 bag-valve-mask device for, 171 basic life support for, 169–171, 170b–172b, 170f cardiopulmonary resuscitation for, 169–171 chest compressions for, 169, 171b laryngospasm in, 24 lidocaine dosage for, 149t local anesthetic dosage for, 148–149, 149t respiratory distress in, 170 respiratory failure in, 169 Chin lift, 22, 168f Chitosan-based hemostatic products, 91t, 92, 100 Chlorpromazine, 83t, 144 Chronic obstructive pulmonary disease, 6t Clopidogrel, 99 Closed circuit capnography, 136, 138 Closed lock, acute, 122b, 122–124, 123f Clots, liver, 94 Coagulation deficiency, 99–100 Coagulopathy, 6t Coarctation of the aorta, 34 Cocaine, 110 Collagen wound dressings, 90–91, 91t Colloid solutions, for acute blood loss, 94 Complex partial seizures, 71 Condylar dislocation, 120f Congenital syndromes, 34 Consciousness loss of See Loss of consciousness partial seizures without impairment of, 71 Consultation, medical, 2, Contact allergies, 54 Contact dermatitis, 54 Coronary artery bypass grafting, 33 Coronary artery disease deaths caused by, 29 diabetes and, 127 medical management of, 32 preoperative evaluation of, 6t risk factors for, 30b Corticosteroids anaphylaxis treated with, 64, 64t diseases treated with, 157b recommended use of, 159b supplemental uses of, 159, 159b Cortisol, 157, 159 Costochondritis, 37 CPR See Cardiopulmonary resuscitation Cranial nerve paralysis, 153 Cricothyroidotomy, for complete foreign body obstruction, 17, 18f–19f Crush injuries, 86f Crystalloid solutions, for acute blood loss, 94, 95f 181 I D  Index D Dantrolene sodium, 135–136, 136f, 138 Davis Drug Guide, Deep venous thrombosis, 36 Defibrillator automated external See Automated external defibrillator manual, 174 Dehydration, in pregnancy, 106, 106f Dehydroepiandrosterone, 157 Dentoalveolar infections, in diabetic patients, 131 Depression, 38 Dermatitis, 54 Dexamethasone, 161–162 Dextrose in water, 128 Diabetes blood glucose monitoring in, 127 characteristics of, 125 classification of, 125–126, 126t coronary artery disease and, 127 gestational, 106–107, 126 hemoglobin A1c levels in, 127 insulin for, 126 in pregnancy, 106–107, 107f preoperative evaluation of, 6t pretreatment assessment of, 126f, 126–127 sulfonylureas for, 126–127 type 1, 125, 126t type 2, 125, 126t Diabetic emergencies hyperglycemia, 130–131 hypoglycemia See Hypoglycemia infections, 131 Diabetic ketoacidosis, 130–131 Diaphoresis, 107 Diazepam, 45 Diphenhydramine, 13, 60, 64t Dipyridamole, 99 Dislocation, temporomandibular joint, 119–122, 120b, 120f–122f Dopamine, 65 Drug abuse, during pregnancy, 110 Drug fever, 58–59 Drug reactions 182 to antibiotics, 55–57 to cephalosporins, 57 description of, 51, 55 to local anesthetics, 57 penicillin, 55–57 to vancomycin, 57 Drug-eluting stents, 33 Drugs, emergency, 11–13 Drugs.com medication guide, DVT See Deep venous thrombosis Dystonia, 120 E Echocardiograms, 32 Eclampsia, 108–109, 109f Electrocautery, 93 Embolism, pulmonary, 36 Emergency care, 13b Emergency drugs, 11–13 Emergency equipment for allergic events, 61b description of, 10–11 nasopharyngeal airway, 10, 10f oropharyngeal airway, 10, 10f types of, 10f Emergency kit description of, 9, 11f drugs in See Emergency drugs emergency medical situations that require, 14t for malignant hyperthermia, 136, 136b, 136f storage of, 13 Emergency plan, 10 Ephedrine, 116 Epilepsy definition of, 69 preoperative evaluation of, 6t Epinephrine anaphylactoid reaction treated with, 63–64, 64t anaphylaxis treated with, 63–64, 64t asthma attack treated with, 109 bronchospasm managed with, 24, 26 description of, 13 dysrhythmia risks, 24 Index H in hyperthyroidism patients, 142 lidocaine with, 148t Epocrates, Equipment, emergency for allergic events, 61b description of, 10–11 nasopharyngeal airway, 10, 10f oropharyngeal airway, 10, 10f types of, 10f Erythema multiforme, 56 Erythroderma, 56 Esmolol, 114 Esophageal dysmotility, 37 Esophageal pain, 37 Ester local anesthetics, 148 Ethyl chloride vapocoolant, 122, 123f F Facial nerve palsy, 152b, 152–153, 153f Fentanyl, 57 Fertility rates, 103 Fibrin sealant/glue, 91t, 93 5-HT3 receptor antagonists, 83 Fluid replacement therapy, for acute blood loss, 94, 95f–96f, 96t Foam cells, 29 Food allergies, 59 Food poisoning, 78t Foreign body obstruction, 16f–18f, 16–17 G Gag reflex, 77–79, 83 Gastroesophageal reflux disease, 37, 78t Gelatin sponges, absorbable, 90, 91t, 92f Gelfoam, 90, 91t, 92f Gell-Coombs classification, of allergic reactions, 52, 52f, 66 Generalized seizures, 70–71 Gestational diabetes, 106–107, 126 Glucagon, 64t, 64–65 Glucocorticoids, 156 Glucose, 12, 13f Glucose meters, 128, 129f Gow-Gates technique, 153 Granisetron, 83t Greater palatine foramen, 79f H Head tilt, 168f Heart failure, 6t Heart rate, 113f Hemoglobin A1c, 127 Hemorrhagic emergencies See also Bleeding blood transfusion for, 94–96, 95f–96f, 96t in coagulation defect patients, 99–100 high-risk patients for, 100 intraoperative bleeding bony bleeding, 86–87 description of, 86 electrocautery for, 93 hemostatic agents for, 88, 90–93, 91t, 92f inferior alveolar neurovascular bundle, 88 management algorithm for, 87f management of, 89–93, 90f, 91t, 92f–93f maxillofacial vascular structures as cause of, 88 nasal mucosa, 88–89, 89f soft tissue, 86 sutures for, 89–90, 90f lip injury, 98, 98f oral bleeding, 96–98, 97b, 97f–98f overview of, 85 postextraction bleeding, 93–94 postoperative bleeding, 93–94, 100 preoperative screening for, 85 summary of, 100 tongue lacerations, 96, 97b, 97f–98f vessel ligation for, 98, 99f Hemostatic agents, 88, 90–93, 91t Heroin, 110 Histamine blockers, 61 Horizontal mattress sutures, 89–90, 90f Hydrocortisone sodium succinate, 161 Hypercarbia, 114 Hyperemesis gravidarum, 106 183 I H  Index Hyperglycemia, 130–131 Hypersensitivity reactions, 52, 53f, 54 Hypertension acute, 114 antihypertensive medications for, 74 aortic dissection risks, 34 causes of, 113b classification of, 113t definition of, 113 elective treatment of, 114 esmolol for, 114 during intravenous sedation, 114 labetalol for, 114 malignant, 114 management of, 114 pregnancy-induced, 108 preoperative evaluation of, 7t stroke caused by, 74 Hypertensive crisis, 114 Hypertensive emergency, 114 Hypertensive urgency, 114 Hyperthermia malignant See Malignant hyperthermia in thyroid crisis, 142, 144 Hyperthyroidism, 141–142, 141b–142b Hyperventilation, 19–20 Hypnotics, 56t, 58 Hypoglycemia definition of, 127 etiology of, 127–128 glucose-containing beverages for, 128 levels of, 127, 127f in pregnancy, 107, 107f relapse of, 130 summary of, 131 symptoms of, 13t, 128b treatment of, 13t, 128–130, 129f Hypotension acute, 116, 117f aortocaval compression syndrome as cause of, 116 causes of, 115b definition of, 114 during intravenous sedation, 116 neurocardiogenic syncope as cause of, 115, 115f orthostatic, 115–116, 116b 184 in pregnancy, 104b, 104–105, 105f supine hypotension syndrome, 104, 104b, 105f, 116 Hypothalamic-pituitary-adrenal axis, 157f Hypothyroidism, 141, 141b Hypovolemia, 115–116 Hypoxia, 114 I IANV bundle See Inferior alveolar neurovascular bundle Immunoglobulin E-mediated hypersensitivity reaction, 52, 53f, 54, 59, 66 Immunoglobulin G, 54 Immunoglobulin M, 54 Infants, 174–175 See also Children Infections, in diabetic patients, 131 Infectious pericarditis, 37 Inferior alveolar nerve block description of, 121 needle breakage during, 153, 153f Inferior alveolar neurovascular bundle, 88 Inferior vena cava syndrome, 116 Injectable drugs, 13 In-stent re-thrombosis, 33 Insulin, 126, 130 International Registry of Acute Aortic Dissection, 33 Intra-articular injections, for temporomandibular joint pain, 121 Intraoperative bleeding bony bleeding, 86–87 description of, 86 electrocautery for, 93 hemostatic agents for, 88, 90–93, 91t, 92f inferior alveolar neurovascular bundle, 88 management algorithm for, 87f management of, 89–93, 90f, 91t, 92f–93f maxillofacial vascular structures as cause of, 88 nasal mucosa, 88–89, 89f soft tissue, 86 sutures for, 89–90, 90f Intraosseous bleeding, 88 Index M Intravenous sedation, hypertension during, 114 Ischemic pain, 32b J Jaw thrust, 22 L Labetalol, 114 Lacerations 98, 96, 97b, 97f–98f tongue, 96, 97b, 97f–98f Laryngospasm, 22–24, 24b–25b, 25f Larynx, foreign body obstruction in, 16f Lasers, for hemostasis, 93, 93f Late-phase hypersensitivity, 52 Latex, allergic reactions to, 58 Lidocaine with epinephrine characteristics of, 148t dosage of, in children, 149t toxicity caused by, 151f Life support See Advanced cardiac life support; Basic life support Lip injury, 85, 86f, 98, 98f Lipid emulsion infusion, for local anesthetic overdose, 150 Liver clots, 94 Liver disease, 7t Local anesthetics allergic reactions to, 153 amide, 148 anaphylactic reactions to, 57 in children, 148–149, 149t commonly used types of, 148t cranial nerve paralysis caused by, 153 description of, 147 dosage of, 148t, 148–149 ester, 148 facial nerve palsy caused by, 152b, 152–153, 153f gag reflex managed with, 79, 79f greater palatine foramen delivery of, 79, 79f intravascular injection of, 152 lipid emulsion infusion for overdose of, 150 needle breakage during injection of, 153f, 153–154 overdose of, 149f–151f, 149–150 in pediatric patients, 148–149, 149t summary of, 154 in tongue laceration repair, 96–97 vasoconstrictors added to, 152 Loeys-Dietz syndrome, 34 Loss of consciousness See also Syncope causes of, 48b hyperventilation as cause of, 19 Ludwig angina, 131 M Malignant hypertension, 114 Malignant hyperthermia calcium concentrations and, 134 capnography monitoring of, 136, 138 dantrolene sodium for, 135–136, 136f, 138 definition of, 133 epidemiology of, 134 in vitro contraction test for, 134 management of, 135–138, 136b–137b, 136f–138f oxygen supplementation for, 138 pathophysiology of, 134 prevalence of, 134 signs and symptoms of, 136, 136b summary of, 138 transfer of care for, 138f triggering agents for, 135b Malignant Hyperthermia Association of the United States, 135, 138 Marfan syndrome, 34 Medical assessment description of, medical questionnaire, 2, 3f–4f medication consultation, 2, medications, preoperative evaluation, Medical emergencies, 185 I M  Index Medical history description of, in pregnant patients, 110–111 Medical questionnaire, 2, 3f–4f Medication(s) See also specific drug entries history-taking about, 7t preoperative evaluation of, Medication consultation, 2, Mepivacaine without epinephrine, 148t Methamphetamine, 110 Methylprednisolone, 64t Metoclopramide, 83t MHAUS See Malignant Hyperthermia Association of the United States Microfibrillar collagen, 91t, 92 Mild allergic reactions, 60–61, 62f, 64 Mineralocorticoids, 156–157 Morning sickness, 106 Multifilament sutures, 89 Muscle relaxants perianesthetic anaphylaxis caused by, 56t, 58 temporomandibular joint pain managed with, 121, 122b Musculoskeletal chest pain, 37–38 Myocardial infarction deaths caused by, 29 description of, 6t emergency response to, 39–40 non-ST-elevation, 29, 31–32, 40 ST-elevation, 29, 31–32, 39–40 symptoms of, 13t Myocardial ischemia, stress-induced, 38 Myoclonic seizures, 71 Myoclonus, 71 N Nasal mucosal bleeding, 88–89, 89f Nasal packing, 88–89, 89f Nasopharyngeal airway, 10, 10f National Registry of Myocardial Infarction, 40 Nausea and vomiting acute vomiting, 80, 81f during anesthesia, 77, 80, 82f 186 causes of, 78t, 78–79 definition of, 77 management of, 79–83, 80f–82f, 83t morning sickness, 106 phases of, 77 postoperative, 80, 82f, 82–83, 83t in pregnancy, 78t, 106, 106b in sedated patients, 80, 82f simple nausea, 79, 80f summary of, 83 vomitus odor, 80, 81f Needle breakage, during local anesthetic injection, 153f, 153–154 Needle cricothyroidotomy, 17, 19f Neurally mediated reflex faints, 45, 47 Neurocardiogenic syncope, 115, 115f Neuroglycemia, 127 Neuromuscular blocking agents, 55 Nitroglycerin, 12–13, 40 Nitrous oxide, 82, 135 Non-ST-elevation myocardial infarction, 29, 31–32, 40 Nonsteroidal anti-inflammatory drugs (NSAIDs) bleeding risks, 85, 99 pregnancy contraindications for, 105–106 temporomandibular joint pain managed with, 121, 122b thyroid crisis contraindications for, 144 O Obstruction airway, 22, 23f foreign body, 16f–18f, 16–17 Odors, 78t, 79 Open cricothyroidotomy, 17, 18f Opioids anaphylactic reactions to, 57–58 perianesthetic anaphylaxis caused by, 56t Oral bleeding, 96–98, 97b, 97f–98f Oral mucosa injury, 98, 98f Oral sedation, 45, 46f Oral surgery, 162 Oropharyngeal airway, 10, 10f Index P Oropharyngeal suctioning, 23 Orthostatic hypotension, 115–116, 116b Orthostatic syncope, 47 Ostene, 91t, 92 Oxidized cellulose, 91t, 91–92, 92f Oxygen cylinder, 10, 10f Oxygen supplementation acute coronary syndrome managed with, 40–41 anaphylactoid reaction managed with, 62–63 anaphylaxis managed with, 62–63 aspiration managed with, 26 in basic life support, 167 bronchospasm treated with, 24 delivery methods for, 10, 12 malignant hyperthermia managed with, 138 postoperative nausea and vomiting prevention with, 82 syncope managed with, 48, 49f P Pacemakers, 174 Pain in acute coronary syndrome, 31 aortic aneurysm-related, 36 dental, during pregnancy, 105–106 ischemic, 32b temporomandibular joint, intra-articular injections for, 121 Partial seizures, 71 PE See Pulmonary embolism Pediatrics See Children Penicillin, allergic reactions to, 55–57 Peptic ulcer disease, 37, 78t Percutaneous transluminal coronary angioplasty, 32 Perianesthetic anaphylaxis anesthetic agents that cause, 56t, 57–58 hypnotic induction agents as cause of, 56t, 58 local anesthetics as cause of, 57 prevention of, 55, 66 testing for, 66 Pericarditis, infectious, 37 Pharynx, 22, 23f Plaque, atherosclerotic, 29 Pleural effusions, 37 Pleuritic chest pain, 37 Pocket PC drug guide, PONV See Postoperative nausea and vomiting Postextraction bleeding, 93–94 Postoperative bleeding, 93–94, 100 Postoperative nausea and vomiting, 80, 82f, 82–83, 83t Postsurgical endocrine effect, 131 Postural hypotension, 115 Potassium deficits, 130 Prebreakfast hyperglycemia, 130 Prednisone, 64t Preeclampsia, 108, 108f Pregnancy asthma in, 109, 110b, 110f blood volume in, 104 dehydration in, 106, 106f dental care during, 110, 111f dental pain during, 105–106 diabetic emergencies in, 106–107, 107f, 126 drug abuse during, 110 eclampsia in, 108–109, 109f hyperemesis gravidarum in, 106 hypotension in, 104b, 104–105, 105f medical history-taking, 110–111 morning sickness in, 106 nausea and vomiting in, 78t, 106, 106b nonsteroidal anti-inflammatory drug contraindication in, 105–106 overview of, 103–104 preeclampsia in, 108, 108f sepsis during, 104 stages of, 103 status epilepticus in, 109 supine hypotension syndrome during, 104, 104b, 105f, 116 syncope during, 105 systemic changes during, 104 trimesters of, 103 uterine changes during, 104 Preoperative evaluation, Pretreatment evaluation algorithm for, 8f medical assessment See Medical assessment risk analysis, 5, 6t–7t, Prilocaine, 149 187 I P  Index Primary adrenal insufficiency, 157–158, 158b, 158t Prochlorperazine, 83, 83t Promethazine, 83t Pulmonary aspiration, 26 Pulmonary embolism, 36 Pulseless ventricular tachycardia, 173 R Rebound hyperglycemia, 130 Reduction, of dislocated temporomandibular joint, 121, 122f Referrals for acute closed lock, 124 for asthma, 110b for temporomandibular joint dislocation, 122 Renal insufficiency, 7t Rescue breaths in adults, 167b, 168 in children, 169, 171b Respiratory alkalosis, 19, 145 Respiratory emergencies airway obstruction, 22 in anesthetized patients, 15, 22–26 aspiration, 26 asthma, 20b, 20–22, 21f foreign body obstruction, 16f–18f, 16–17 hyperventilation, 19–20 laryngospasm, 22–24, 24b–25b, 25f respiratory arrest, 22–26 treatment of, 13t types of, 15 Retching, 77 Revascularization, of stenotic lesions, 32 Rhinitis, 59 Rhinosinusitis, 59 Risk analysis, 5, 6t–7t, Risk mitigation, Running sutures, 89 Ruptured aortic aneurysm, 35–36 RyR1 protein, 134 188 S Samter syndrome, 59 Sarcoplasmic reticulum, 134 Secondary adrenal insufficiency, 158, 158b, 158t Sedation airway obstruction during, 22, 23f intravenous hypertension during, 114 hypotension during, 116 in malignant hyperthermia-susceptible patients, 135 nausea and vomiting during, 80, 82f oral, 45, 46f Seizures absence, 70–71 classification of, 70b, 70f, 70–71 description of, 69 eclamptic, 108 emergency treatment of, 13t generalized, 70–71 management of, 71–72, 72f myoclonic, 71 partial, 71 symptoms of, 13t tonic-clonic, 70–71, 149 unclassifiable, 71 Sepsis, 104 Shellfish allergy, 59 Shivering, 144 Sildenafil, 40 Silent chest, 21 Simple nausea, 79, 80f Sinus tachycardia, 142, 145f Situational syncope, 47 Skin testing for cephalosporin reactions, 57 for penicillin reactions, 56 Soft tissue bleeding, 86 Somogyi effect, 130 Stable angina, 30–31 Staff training in basic life support, 165 in syncope, 45 Status epilepticus, 109 Index T ST-elevation myocardial infarction, 29, 31–32, 39–40 Stents, 32–33, 33f Steroid hormones, 156–157 Stevens-Johnson syndrome, 54 Stomach irritants, 78t Stress hyperglycemia, 131 Stress relief protocols, 45 Stress tests, 32 Stroke cardioembolic, 74 death rate associated with, 72 emergency management of, 74–75, 75f risk factors for, 72–74, 73f, 73t signs of, 75b transient ischemic attacks versus, 73–74, 75b Stroke volume, 113f Subclinical hyperthyroidism, 141, 142b Succinylcholine, 24, 135 Sulfonylureas, 126–127 Supine hypotension syndrome, 104, 104b, 105f, 116 Supraventricular tachycardia, 145 Surgicel, 91t, 91–92, 92f Sutures, 89–90, 90f Syncope See also Loss of consciousness algorithm for, 49f aromatic ammonia for, 12, 12f carotid sinus, 47 cerebrovascular, 47f, 48 clinical presentation of, 45, 47b differential diagnosis of, 45, 47b, 47–48 emergency treatment of, 13t incidence of, 44 management of, 48b, 48–50, 49f neurally mediated reflex faints versus, 45, 47 neurocardiogenic, 115, 115f oral sedation for prevention of, 45 orthostatic, 47 in pregnancy, 105 prevention of, 44–45 situational, 47 staff training in, 45 stress relief protocols for, 45 symptoms of, 13t Trendelenburg position for, 48, 49f, 50 vasovagal, 47, 47f T T3 See Triiodothyronine T4 See Thyroxine Tachycardia pulseless ventricular, 173 sinus, 142, 145, 145f Tardive dystonia, 120 Temporomandibular joint emergencies acute closed lock, 122b, 122–124, 123f dislocation, 119–122, 120b, 120f–122f Tertiary adrenal insufficiency, 158, 158b Thrombophilia, 36 Thyroid crisis atrial fibrillation caused by, 141, 142f, 144b, 145f, 145–146 definition of, 140 diagnosis of, 140, 143, 143b emergency management of, 143–145, 144f hyperthermia in, 142, 144 manifestations of, 142 mental disorientation in, 142 precipitating factors, 142, 143b prevention of, 142–143 sinus tachycardia in, 142, 145f summary of, 146 Thyroid disease, 141b, 141–142 Thyroid gland, 140 Thyroid storm, 140 Thyrotoxicosis, 31, 141 Thyroxine, 140 TIAs See Transient ischemic attacks Ticlopidine, 74 Tongue blades, 123f Tongue lacerations, 96, 97b, 97f–98f Tonic-clonic seizures description of, 70–71 local anesthetic overdose as cause of, 149 Trachea, foreign body obstruction in, 16f Tracheobronchial tree, 16f Tracheostomy, 17, 18f 189 www.ajlobby.com I T  Index Tranexamic acid, 91t, 92 Transfusion, blood, 94–96, 95f Transfusion reactions, 54 Transient ischemic attacks, 73–74, 75b, 75f Trendelenburg position, 12, 48, 49f, 50, 107 Triazolam, 45 Tricyclic antidepressants, for temporomandibular joint pain, 121, 122b Triiodothyronine, 140 Trismus, 122 Turner syndrome, 34 Type hypersensitivity, 52, 53f Vasoconstrictors, 152 Vasopressors, 65 Vasovagal syncope, 47, 47f Ventricular fibrillation, 173 Vertical mattress sutures, 89–90, 90f Vessel ligation, 98, 99f Virchow’s triad, 36 Vital signs, 112 Vomiting See Nausea and vomiting von Willebrand disease, 100 U Warfarin, 7t, 99 Wells score, 36 Wound dressings, 90–91, 91t Unconscious patients, foreign body obstruction in, 17, 17f Unstable angina, 29, 31, 40 V W X Xerostomia, Valsalva maneuver, 47 Vancomycin, 57 190 www.ajlobby.com .. .Medical Emergencies in Dental Practice www.ajlobby.com www.ajlobby.com Medical Emergencies in Dental Practice Orrett E Ogle, dds Lecturer, Mona Dental Program Faculty of Medicine University... manage medical emergencies that they may encounter The ability to initiate effective primary management is the key to minimizing morbidity and mortality In general, medical emergencies in dental practice. .. frequency of medical emergencies among patients in a dental school setting J Dent Educ 2010;74:392–396 3.  Atherton GJ, McCaul JA, Williams SA Medical emergencies in general dental practice in Great