📖 Oral Medicine

Emergency conditions in Dental Clinics

Hypoadrenalism - Usually the patient is known to have Addison's disease or to be taking steroids long term and has forgotten to take the tablets.

Signs and symptoms

• Pallor
• Confusion
• Rapid weak pulse.

Treatment:

Give oxygen
Give 200 mg hydrocortisone sodium succinate by slow i.v. injection.
 Give steroid replacement
 Determining and managing underlying cause once the crisis over.

If required:

• Transfer to Emergeny hostpital
• Fluids and further hydrocortisone, both i.v.

Acute asthma - Exposure to antigen but precipitated by many factors including anxiety.

Signs and symptoms

• Persistent shortness of breath poorly relieved by bronchodilators
• Restlessness and exhaustion
• Tachycardia greater than 110 beats/min and low peak expiratory flow
• Respirations may be so shallow in severe cases that wheezing is absent.

Treatment
Excluded respiratory obstruction
Sit the patient up
Give oxygen

Salbutamol (Ventolin) via a nebuliser (2.5-5 mg of 1 mg/ml nebuliser solution) or via a large-volume spacer (two puffs of a metered dose inhaler 10-20 times: one puff every 30 seconds up to 10 puffs for a child)
Reassure and allow home if recovered.

• Bronchodilatation.

If Major Problem recommend to hospital Emergeny

• Hydrocortisone sodium succinate i.v.: adults 200 mg; child 100 mg
• Add ipratropium 0.5 mg to nebulised salbutamol
• Aminophylline slow i.v. injection of 250 mg in 10 ml over at least 20 minutes: monitor or keep finger on pulse during injection.

Caution in epilepsy: rapid injection of aminophylline may cause arrhythmias and convulsions.

Caution in patients already receiving theophylline: arrhythmias or convulsions may occur.

Anaphylactic shock

Signs and symptoms

• Paraesthesia, flushing and swelling of face, especially eyelids and lips (Fig. 13)
• generalised urticaria, especially hands and feet
• wheezing and difficulty in breathing
• rapid weak pulse.

These may develop over 15 to 30 minutes following the oral administration of a drug or rapidly over a few minutes following i.v. drug administration.

Treatment

Lay patient flat and raise feet
Give oxygen
Give 0.5 ml epinephrine (adrenaline) 1 mg/ml (1 in
1000) intramuscular
— 0.25 ml for 6-12 years
— 0.12 ml for 6 months to 6 years
repeated every 10 min until improvement.

Requires prompt energetic treatment of

• laryngeal oedema
• bronchospasm
• hypotension.

• Chlorphenamine (chlorpheniramine) 10 mg in 1 ml intramuscular or slow i.v. injection
• Hydrocortisone sodium succinate 200 mg by slow i.v. injection: valuable as action persists after that of adrenaline has worn off
• Fluids i.v. (colloids) infused rapidly if shock not responding quickly to adrenaline.

Stroke - Stroke results from either cerebral haemorrhage or cerebral ischaemia.

Signs and symptoms

• Confusion followed by signs and symptoms of focal brain damage
• Hemiplegia or quadriplegia
• Sensory loss
• Dysphasia
• Locked-in syndrome (aware, but unable to respond).

Treatment

Maintain and transfer for further investigation.

Benzodiazepine overdose - Overdose can result from a large or a fast dose of benzodiazepine or can occur in a sensitive patient.

Signs and symptoms

• Deeply sedated
• Severe respiratory depression.

Treatment

Flumazenil (Annexate) 200 mg over 15 seconds as 100 mg/ml i.v. followed by 100 mg every 1 minute up to maximum of 1 mg Maintain airway with head tilt/chin lift 
Give oxygen.

Treatment

The action of the benzodiazepine is reversed with the specific antagonist.

Angina and myocardial infarction

Signs and symptoms

• Sudden onset of severe crushing pain across front of chest, which may radiate towards the shoulder and down the left arm or into the neck and jaw; pain from angina usually radiates down left arm
Skin pale and clammy
Shallow respirations
Nausea
Weak pulse and hypotension
If the pain not relieved by glyceryl trinitrate (GTN) then cause is myocardial infarction rather than angina.

First-line treatment of angina and myocardial infarction

Allow patient to rest in position that feels most comfortable:

• in presence of breathlessness this is likely to be the sitting position, whereas syncopal patients will want to lie flat
• often an intermediate position will be most appropriate.

Angina - 

Angina results from reduced coronary artery lumen diameter because of atheromatous plaques
Myocardial infarction is usually the result of thrombosis in a coronary artery.

Angina is relieved by rest and nitrates:
 
• Glyceryl trinitrate spray 400 mg metered dose (sprayed on oral mucosa or under tongue and mouth then closed)
• Give oxygen
• Allow home if attack is mild and the patient recovers rapidly.

Myocardial infarction

If a myocardial infarction is suspected:

• give oxygen
• aspirin tablet 300 mg chewed.

• Pain control
• Vasodilatation of blood vessels to reduce load on heart.

Further management for severe angina or myocardial infarction

• Transfer to Emergency
• Diamorphine 5 mg (2.5 mg in older people) by slow i.v. injection (1 mg/min)
• Early thrombolytic therapy reduces mortality.

Cardiac arrest

• Most cardiac arrests result from arrhythmias associated with acute myocardial infarction or chronic ischaemic heart disease
• The heart arrests in one of three rhythms 
— VF (ventricular fibrillation) or pulseless VT (ventricular tachycardia)
— asystole
— PEA (pulseless electrical activity) or EMD (electromechanical dissociation).

Signs and symptoms

• Unconscious
• No breathing
• Absent carotid pulse.

Treatment

• Circulation failure for 4 minutes, or less if the patient is already hypoxaemic, will lead to irreversible brain damage
• Institute early basic life support  as holding procedure until early advanced life support is available.

• Transfer to Emergency
• Advanced life support.

Advanced life support for cardiac arrest

Advanced airway management techniques and specific treatment of the underlying cause of cardiac arrest constitute advanced life support (ALS).