ภาวะฉุกเฉินทางการแพทย์ (Medical Emergencies) ในคลินิกทันตกรรม

1. ภาวะฉุกเฉินทางการแพทย์ (Medical Emergencies) ในคลินิกทันตกรรม • การป้องกัน (Prevention) • การจัดการ (Management)

2. Patient at Risk Dentist at Risk

3. Introduction • Emergencies in dental practice can occur to any person, any time. • How to manage, it is the most difficult thing at time occurred.

4. The majority emergency is syncope. Introduction

5. allergic reaction angina pectoris postural hypotension seizures asthmatic attack hyperventilation hypoglycemia anaphylactic reaction cerebrovascular accident adrenal insufficiency thyroid storm etc Introduction Others

6. Consciousness Composition of consciousness • Brain • O2 • Glucose • Effective hemodynamic

7. Fact … of human brain • Uses O2 approx. 20% of total O2 • Uses glucose approx. 65% of total glucose • Uses approx. 20% of total circulation/min (750 ml.min.)

8. Consciousness Balance mechanism of : • Hemodynamic • Respiration • Metabolism • Neurologic

9. Unconsciousness Caused from impair …….. • Hemodynamic • Respiration • Metabolism • Neurologic

10. How to avoid these complications? • Prevention is the best • Good history taking • Good preoperative preparation • Good operative controls

11. Vasodepressor syncope Drug administration /ingestion Orthostatic hypotension Epilepsy Hypoglycemic reaction Acute adrenal insufficiency Acute allergic reaction Acute myocardial infarction Cerebrovascular accident Hyperglycemic reaction Hyperventilation syndrome Possible causes of unconsciousness in the dental office

12. Alteration of consciousness • Cerebrovascular accident (CVA) • Seizures • Hypoglycemia / Hyperglycemia • Adrenal insufficiency • Thyroid storm • Hyperventilation • Drug overdose

13. Unconsciousness Syncope is the most common occurred.

14. Factors influence • Stress and anxiety • Health status • Drugs

15. How syncope occur? In normal : circulation compensation mechanism play role in correction of deficiency O2 supply to the brain.

16. How syncope occur? In syncope : circulation compensation mechanism fail to increase O2 need from the brain

17. Signs for syncope Early : Feeling of warmth Loss of color : pale or ashen=gray skin tone Heavy perspiration Complaints of feeling “bad” of “faint” Nausea Blood pressure approximately baseline Rapid heart rate

18. Signs for syncope Late : • Pupillary dilation • Yawning • Hyperpnea • Cold hands and feet • Hypotension • Bradycardia • Dizziness • Loss of consciousness

19. Critical consideration • Timing of detection and correction • Maintain O2 level to the brain : Airway, Breathing, Circulation (ABC - Basic life support)

20. Orthostatic hypotension • Failure of the baroreceptor reflex • Loss of compensate mechanism • Reflex bradycardia • Loss of consciousness

21. Drugs producing orthostatic hypotension

22. Unconsciousness Assessment : Check for Breathing • Look the chest to rise and fall • Listen for air escaping during exhalation • Feel for the flow of air

23. Unconsciousness : no response to stimuli P - position : SUPINE Call for help : EMS activation A, B = Airway (head tilt - chin lift) Artificial Assisted Breathing (if no self respiration)

24. C = check circulation Carotid pulse absent Carotid pulse present Check medical history Vital signs Activate EMS Recovery unrecovery Initiate CPR Immediate transportation Orthostatic hypotension Vasodepressor syncope

25. Sequence of BCLS • Assessment • EMS Activation • ABCs of CPR • D of Defibrillation

26. ABCs of CPR • Airway • Breathing • Circulation

27. Airway • Position the victim • Rescuer position • Open the Airway • Head Tilt - Chin Lift Maneuver • Jaw Thrust Maneuver • Recommendations for Opening the Airway

28. Mechanism Inadequate delivery of blood or oxygen to the brain Clinical example Acute adrenal insufficiency Orthostatic hypotension Vasodepressor syncope Classification of causes of unconsciousness by mechanism

29. Mechanism Systemic or local metabolic deficiencies Clinical example Acute allergic reaction Drug ingestion and adminstration Nitrites and nitrates Diuretics Sedatives-narcotics Local anesthetics Hyperglycemia Hyperventilation Hypoglycemia Classification of causes of unconsciousness by mechanism

30. Mechanism Direct or reflex effects on nervous system Psychic mechanisms Clinical example Cerebrovascular accident Convulsive episodes Emotional disturbances Hyperventilation Vasodepressor syncope Classification of causes of unconsciousness by mechanism

31. CHEST PAIN

32. Cardiac related Angina pectoris Myocardial infarction Non-cardiac related Muscle strain Pericarditis Esophagitis Hiatal hernia Pulmonary embolism Dissecting aortic aneurysm Acute indigestion Intestinal “gas” Causes of chest pain

34. Chest pain is one of the major clinical clues to the presence of significant heart disease.

35. Definition of Terms “Atherosclerosis” is a special type of thickening and hardening of medium - sized and large arteries because of deposits of a fatty substance. • is an ongoing process • is a reactive biologic response of arteries to the forces being generated by the flow of blood.

36. Atherosclerosis is the major factor underlying all forms cardiovascular disease.

37. Pathology of atherosclerosis

38. Normal structure

39. Development of atherosclerosis Proliferative change

40. Development of atherosclerosis Lipid deposition

41. The development of ACS Early plaque formation Significant plaque formation Plaque rupture Thrombus

42. Coronary artery disease is the presence of atherosclerosis in the coronary arteries. • Angina pectoris • Myocardial infarction

43. Angina is a transient discomfort (usually less than 15 minutes) due to a temporary lack of adequate blood supply to the heart muscle.

44. Myocardialinfarction is defined as death of heart muscle (myocardium) as the result of prolonged inadequate blood flow and oxygen delivery.

45. Acute coronary syndromes encompasses symptomatic condition resulting in an inadequate blood supply to the heart; including unstable angina and AMI.

46. AMI (heart attack) is defined as death of heart tissue due to blockage of a coronary artery caused by atherosclerosis and thrombus formation.

47. Unstable angina • Angina that is continuing, prolonged or occurring at rest. • Represents a syndrome that lies between angina pectoris and AMI.

48. Unstable Angina pectoris --------------> AMI Angina

49. Risk factors : Heart attack • Risk factors that cannot be changed Age Heredity Gender Race

50. Cigarette smoking High blood pressure High blood cholesterol level Physical inactivity Diabetes Obesity Excessive stress Risk factors that can be changed