Anesthetic complications and office emergencies 2.

Those attributed to the insertion of the

needle

● Syncope
What is anesthetic complication?
● Muscle trismus
● It is defined as any deviation from the
normally expected pattern during or after ● Pain or hyperalgesia
the securing of regional anesthesia.
● Edema
CLASSIFICATION OF COMPLICATIONS:
● Infections
1. Primary or Secondary
● Broken needles
● Primary - Caused and manifested
● Prolonged anesthesia
at the time of anesthesia
● Hematoma
● Secondary – May be caused at the
time of insertion of the needle and ● Sloughing
injection of the solution
● Bizarre neurological symptoms
2. Mild or Severe

● Mild – Exhibits a slight change

from normally expected pattern; COMPLICATIONS CAUSED BY ANESTHETIC
reversible without treatment SOLUTION

● Severe – From normally expected Toxicity

pattern that requires a definite
● Toxic overdose
plan of treatment
● Refers to the symptoms
3. Transient or Permanent
manifested as a result of over
● Transient – Severe at time but dosage or excessive administration
leaves no residual effect of the drug

● Permanent – Leaves a residual ● To avoid toxicity, use least possible

effect; mild in nature volume and concentration needed
to secure satisfactory anesthesia
TWO GROUPS OF COMPLICATIONS:
● When the drug is inadvertently
1. Those attributed to the solutions used administered intravascularly,
buildup within the bloodstream is
● Toxicity
so rapid that biotransformation
● Idiosyncrasy and elimination can keep pace only
with difficulty
● Allergy
● It can affect central nervous
● Anaphylactoid reactions
system, respiratory system or
● Infections (contaminated circulatory system
solutions)
● Entire dental cartridge should be
● Local irritations injected over a period of not less
than 1 minute.
 ● All injectable local anesthetics are o Procaine and Lidocaine have
vasodilators. been shown to possess an
anticonvulsant activity
▪ The more vascular the
● Numbness of the oral cavity is caused by
area, more rapid the
the direct effect of the high blood level of
absorption and greater
the local anesthetic in highly vascularized
the possibility of toxic
tissue of it
reaction
● Tonic-clonic seizure occurs when the blood
level of local anesthetic reaches 7.5 to 10.0
ug/ml
CAUSES OF TOXICITY o Redistribution and
● Large dose of local anesthetic drug biotransformation of the agent
continue to occur throughout
● Unusually rapid absorption of drug or IV the episode because the
seizure is short-lived and self-
● Slow biotransformation
limiting
● Slow elimination or redistribution o Leads to cyanosis
● After tonic-clonic seizure, postical
depression occurs
FACTORS THAT CAN CAUSE TOXICITY o Severe depression of cortical
and medullary centers
● Patient’s state of health
SIGNS AND SYMPTOMS OF CNS TOXICITY
● Rapidity of injection

● Route of administration
CEREBRAL CORTEX MEDULLA
● Amount of drug used

● Age Talkative Lethargy

Restlessness Sleepiness
TOXIC EFFECTS ON CENTRAL NERVOUS SYSTEM

● The effect is produced by depression of Apprehensive Unconscious

certain inhibitory centers
Convulsive
o A balance exists between
excitatory and inhibitory
centers within the brain Excited

● Depression of inhibitory areas allows EARLY CNS STIMULATION SYMPTOMS

excitatory actions to occur that leads to
manifestation of CNS stimulation

● The amygdala is the primary site of action

● Subtoxic doses depress hyperexcitable

neurons thereby producing an
anticonvulsant effect
 o Bradycardia and peripheral
vasodilation

● Above 10 ug/ml, massive cardiovascular

collapse occurs

o Intense peripheral vasodilation and

asystole

o Asystole produced by local

anesthetics is virtually irreversible

● Cardiovascular effects predominate with

sudden and total collapse of the system
LATE CNS DEPRESSION SYMPTOMS ● It is a mistake to insert a needle, rapidly
inject the anesthetic solution and
CEREBRAL CORTEX MEDULLA immediately leave the patient unobserved
and unattended
Increase blood pressure Decrease blood pressure
● If adverse signs and symptoms appear
during the injection, it should discontinued
Increase pulse rate Decrese blood pressure and the needle withdrawn

Increase respiratory Decrease heart rate

rate SYMPTOMS

● Chest pain
Nausea and vomitting Respiratory depression
● Shortness of breath
Unconsciousness ● Palpitations

● Lightheadedness

● Diaphoresis

TOXIC EFFECTS ON THE CARDIOVASCULAR SYSTEM ● Hypotension

● Direct effect is only depression in the ● Syncope

myocardium

● Local anesthetics act as antiarrhythmic

agents in relatively low doses

● Lidocaine is effective in suppressing ectopic Management of toxic reactions

pacemakers and controlling ventricular
arrhythmias Immediate, mild and transitory reactions
● 1 to 1.5mg/kg = IV administration (sufficient Early signs and symptoms:
amount to produce an effect)
⚫ Patients is suddenly talktative or jittery
● Above 5.0 ug/ml, severe depression of
cardiac function occurs ⚫ Exhibits apprehension
 ⚫ Restlessness ⚫ Patency of airway by maximally extending
the victim’s head
⚫ Slight drowsiness and sleepiness
Convulsive phase:
⚫ Convulsive
⚫ Patient protection
Management for mild stimulation
⚫ Anticonvulsant IV/IM
⚫ No specific treatment necessary
Depression phase:
⚫ Reassurance by the clinician
⚫ Artificial respiration (assisted/controlled
Management for moderate stimulation ventilation)

⚫ IV injection of barbiturates ⚫ Patient is placed in a semirecumbent

position
⚫ Oxygen inhalation
Pharmacological management of central nervous
Severe reaction
system stimulation
Tonic-Clonic seizure
⚫ Intravenous infusion to quell development
Cause: if generalized seizure

⚫ Seizure occurs suddenly and is short (10 to ⚫ Intravenous administration of 50 to 100mg

15 seconds) it is due to inadvertent of barbiturate, pentobarbital (Nembutal) at
intravascular injection earliest sign of toxicity

⚫ Seizure occurs 2 to 5 minutes after ⚫ Diazepam (Valium), 5 to 10mg IV

injection. It is due to rapid absorption
⚫ Succinylcholine 20-40mg
Management
Pharmacological management of central nervous
⚫ All dental procedures must be stopped and system depression
efforts directed toward protection of the
patient from injury. If mild to moderate CNS depression

⚫ Arms and legs must be restrained ⚫ Patency of airway

⚫ A firm but pliable object such as padded ⚫ Artificial ventilation

tongue blade, cotton towel or rubber bite
⚫ Position that allows gravity to alter venous
block must be quickly inserted between the
return
teeth
If severe CNS depression:
⚫ Suction should be readily available to
remove excess saliva or vomitus ⚫ Positional change

⚫ Patency of airway by maximally extending ⚫ 5% dextrose in water or 5% dextrose in

the victim’s head lactated Ringer’s solution (IV 250-500ml) for
hypovolemia
⚫ Suction should be readily available to
remove excess saliva or vomitus ⚫ Phenylephrine (Neo-Synephrine) 3 to 5 ml
 ⚫ 0.5 mg atropine or 0.2 mg Glycopyrrolate sensitized to a particular drug or chemical
(Robinul) IV/IM for bradycardia derivative
- Acquired or familial *according to Criep
- SIGNS & SYMPTOMS Most common shock
organs: skin (*most common immediate),
mucous membrane and blood vessels
(*most common immediate)
- Reactions may be manifested by:
1. Rashes
2. Urticaria – production of smooth,
Idiosyncrasy elevated patches of skin, wheals, which
are accompanied by intense itching
- DEFINITION Any reaction to a local 3. Angioneurotic edema – localized
anesthetic or drug that cannot be classified swelling of soft tissue, frequently
as toxic or allergic
involves the hands, face, lips, tongue,
● A characteristic which is usually
unexplainable by the usual means pharynx and larynx
(medical, pharmacological, 4. Mucous membrane congestion
psychological) a) Rhinitis
- No relation to the pharmacology of the drug b) Asthmatic symptoms
and may vary in degree from day to day, ● Occasionally, reactions may also
even in the same patient involve: respiratory system (*second
- Can occur as the result of emotional most common immediate anaphylactic
interplay, causing an array of unusual reaction), cardiovascular system and
symptoms smooth muscle of the gastrointestinal
- TREATMENT For the idiosyncratic type of tract
emergency, it is almost impossible to - Mild or severe
outline in advance, since it must depend on - Immediate or delayed
the symptoms manifested - Localized anaphylaxis – when the reaction
⮚ Patient’s airway must be maintained involves only one of these entities as occurs
and adequate oxygenation assured most frequently
⮚ Steps should also be taken to evaluate - Generalized anaphylaxis – when they are
the circulation and support by its all involved
positional changes, drugs, or parental ● Tx for immediate mild and localized
fluids reactions that involve the skin and/or
⮚ Precautions must be exercised to mucous membranes and are
protect the patient from injury to manifested as the production of
himself as a result of convulsive urticaria, pruritis, angioedema and
seizures, loss of consciousness, or conjunctivitis: Diphenhydramine
similar reaction (Benadryl) may be administered orally
in 50 mg doses every 3 to 4 hours
Allergy and anaphylactoid reactions
● Tx for more severe yet localized
- DEFINITION Drug allergy is a specific reactions: Diphenhydramine (Benadryl)
hypersensitivity to a drug or chemical agent may be administered intravenously or
- CAUSE A specific antigen-antibody reaction intramuscularly in 25 to 50 mg doses)
in a patient who has previously been ● Occasionally, severe yet localized
reactions may require the
 subcutaneous or intramuscular
administration of Epinephrine in 0.3 to *Non-ester types are contraindicated
0.5 mg (0.3 to 0.5 mL of 1:1000 Dantrolene Sodium is for Treating episodes of severe
Adrenaline) doses high body temperature (malignant hyperthermia).
- TREATMENT
1. Antihistaminic agents (Benadryl 20 to Complications of Vasocontrictor Drugs
Gingival Retraction Cord impregnated with
50 mg)
Epinephrine
2. Isoproterenol or epinephrine inhalants
- abraded mucosa or gingival epithelium, allows toxic
3. Epinephrine (0.5 ml of 1:1000
level to be reached quickly.
intramuscularly)
– 1mg Epinephrine/inch
4. Aminophylline (0.5 mg intravenously)
5. Oxygen in case of systemic toxic reaction, patient should be
- PREVENTION noted that at future appointments smaller
1. Adequate preanesthetic evaluation concentrations can be used.
must be done Symptoms:
2. No drug or drugs should be used if the 1. Palpitation
patient gives a history if previous 2. Tachycardia
allergic reaction 3. Hypertension
3. No patient should be tested to attempt 4. Headache
to disprove his allergic history Contraindicated for patients with Cardiovascular
● This should be done by the allergist Disease

Allergy testing Patient may also become:

1. Fearful and apprehensive
- Intradermal test Reassure the patient that the effect will subside
- Mucous membrane test shortly.
Remove the Cord promptly

Pharmacogenetic Disorders
-Pharmacogenetics is the study of how the actions of
Local Reactions Caused by Anesthetic Solutions
and reactions to drugs vary with the patient's genes.
1. Contaminated solutions
2. Alcohol-Contaminated Solutions may cause
1.) Malignant Hyperpyrexia (Hyperthermia)
prolonged anesthesia
Excessive release of calcium ion release from the
3. Burning sensations caused by isotonic needle
sarcoplasmic reticulum of muscle causing High
solutions.
metabolism and Respiratory Acidosis.
2.) Tachycardia
Preventions
3.) Unstable BP
1. Cartridges should only be used once
4.) Cyanosis
2. Cartridges should be stored dry in their original
5.) Extreme Fever (108 degrees Fahrenheit)
container
3. Operator should handle only by the stoppered end
6.) Muscle Rigidity
after thoroughly washing hands
4. Rubber diaphragm should be wiped with a
disposable, alcohol sponged before insertion into the
*Respiratory acidosis is a condition that occurs when
syringe and affixing of the needle
the lungs cannot remove all of the carbon dioxide
5. Slow deposition of solution to prevent local tissue
the body produces. This causes body fluids,
damage.
especially the blood, to become too acidic.
6. Avoid excessive volume to prevent local tissue
reaction secondary to pressure created. 1. Pulse (if palpable)
7. Make sure that the cartridge is properly labeled to 2. Respiration(if the volume is satisfactory)
prevent injection of wrong solutions. 3. Color(if satisfactory)

There should be no burning sensation caused by the if the patient will exhibit cyanosis or extreme pallor
isotonic sterile solutions. Persistent irritation or or an ashen gray color associated with an
burning during or after injection warrants an Tachycardia, or Bradycardia or Arrhythmia that is
investigation of the anesthetic solution. previously not present. And if the Pulse is no longer
palpable, then the condition is more than syncope.
Complications attributed to needle insertion or
technical complications Circulation must be restored by artificial ventilation.
1. Syncope(fainting)
-a Neurogenic Shock caused by cerebral ischemia
secondary to vasodilation or in an increase Muscle Trismus
peripheral vascular bed, with a corresponding drop Trismus is any muscle soreness or any limitation of
in blood pressure. motion.
Causes:
Fainting is not always associated with loss of 1. Trauma
consciousness. However, loss of consciousness is an 2. Irritating solutions
extreme manifestation of cerebral ischemia. 3. Hemorrhage
4. Infection
Patient may become Pallor and have a strange
feeling. How to manage
Discontinue any procedures in progress and position Slight exercise and drug therapy may be necessary to
the patient in a semirecline positions, Lower the relieve pain, if sufficiently severe.
back rest while the patient’s legs are elevated. Diazepam(Valium) 2.5 to 5.0mg four times a day
Meprobamate(Miltown or Equanil) 1200 to
Semirecline Position 1600mg/day in 3 or 4 doses
coupled with the application of warm moist
compresses for 15 to 20 minutes per hour.
Mild analgesics for discomfort.

Opening and closing the mouth as well as movement

from side to side for 5 to 10 minutes every 3 to 4
hours will assist recovery.

*This is to aid in the venous return from the lower Hemorrhage and Infection
body and prevent venous congestion of the upper
body. Pain or Hyperesthesia
*The weight of the viscera is not thrown to the Precautions
diaphragm, which may impair respiratory. 1.) Use sharp needles.
*once the patient is conscious. Ask the patient to 2.) Topical anesthesia should be applied to the area
take deep breaths. of insertion
This maneuver assist in venous return while 3.) Multiple insertion should be AVOIDED
providing adequate oxygenation. 4.) Sterile solution
5.) Slow deposition
In case of loss of consciousness, the following should 6.) AVOID excessive volume in constricted areas
be checked to determine the severity of the 7.) the temperature of the solution should be as
condition. close as the body's temperature.
8.) Asepsis must be observed any procedure.

Pharmacogenetic Disorders what is Broken Needles

Pharmacogenetics? Precautions
-study of how the actions of and reactions to drugs 1.) Use sharp needles.
vary with the patient's genes. 2.) Topical anesthesia should be applied to the area
One of the simplest examples is the gene that of insertion
influences BODY WEIGHT. Since many drugs are 3.) Multiple insertion should be AVOIDED
soluble in body fat, people with large amounts of fat
4.) Sterile solution
will have these drug deposited into their fat stores.
5.) Slow deposition
6.) AVOID excessive volume in constricted areas
This means that there are lower levels of the drug
7.) The temperature of the solution should be as
that can reach the actual organs on which they work.
close as the body's temperature.
women show greater response to serotonin specific
antidepressants because women naturally have
Possible causes of pain
lower levels of serotonin than men do. Having low
1.) Blunt needle
level of serotonin may cause depression but at the
2.) Fast deposition
same time, they will respond to serotonin
3.) Infection
replacement much better.
4.) Temperature of the solution
1. Pharmacogenetic Disorders
Malignant Hyperpyrexia
Principles to prevent broken needles
Cause: Excessive Calcium Ion release of the
1.) Do not attempt to force a needle against a
Sarcoplasmic Reticulum (regulates the Ca level in the
resistance.
cytoplasms of cells) uses of calcium:
2.) Do not attempt to change the direction of the
1.) Blood clotting.
needle while it is embedded in the tissue.
2.) Stabilizes blood pressure (by keeping the smooth
3.) Do not use a needle too fine a gauge. Gauge 27
muscle that line the BV toned) normal brain function
and 30 should only be used for superficial injections.
4.) Never use a resterilizable needles.
3.) Cyanosis is due to lack of oxygen caused by the
5.) Do not attempt injections if you are uncertain
increased carbon dioxide concentration in the blood.
about the anatomy of the area of the techniques
This may also be caused by Hypoventilation of the
employed.
person which may lead to;
6.) Do not insert the needle so far as it is out of sight
4.) Tachycardia (lack of oxygen will lead to faster
in tissue. Always leave 1/3 of the length of the
heart rate)
needle outside the tissue.
5.) Muscle Rigidity is caused by the impaired
7.) Do not surprise the patient with a sudden
function of sarcoplasmic reticulum, which regulates
unexpected needle insertion.
the calcium, which is a chemical required for
contraction of muscles.
Prolonged Anesthesia other than from the
Anesthetic solution
Edema -swelling of the tissues -may be caused by
1.) Hemorrhage of the neural sheath - caused by
trauma, infection, allergy, hemorrhage and other
mild trauma of a needle bumping into the nerve,
factors.
which creates pressure and subsequent anesthesia.
Infection
Pressure may cause degeneration of the nerve.
1.) Dentists should constantly apply all means at
Damage to the nerve may cause hyperalgesia and
their command to prevent infection.
not anesthesia.
2.) All instruments should be as aseptic as possible.|
3.) Hands of the Dentist should be cleansed before
Hematoma of those patients whom most likely to
- An effusion of blood into the surrounding tissues as present an emergency problem.
the result of a torn blood vessel. - If Local or Systemic
- But does not preclude any other emergency
Common complication of intraoral regional analgesia possibility

Commonly associated with PSAN and Infraorbital Note the following General appearance:
Nerve Blocks
1. Mental State (Alert or Lethargic)
*Atraumatic puncture of a vein will not produce a 2. Emotional State (calm or excited)
hematoma. 3. Nailbeds, lips (pink, pale or cyanotic)
4. Skin (warm and dry or cold and clammy)
Improper techniques may cause hematoma.
Hematoma secondary to improper needle insertion *Check the vitals:
have no severe consequence other than - Pulse Rate
inconvenience to the patient due to discoloration of
- Blood Pressure
the skin that may persist for a few days. No attempt
- Breathing
should be made to aspirate or to interfere with the
normal absorption of blood in the tissue. They all *Patient must be:
absorb in due time.
- Adequately Ventilated with oxygen
Bizarre Neurological symptoms Patient's may
exhibit: - BP supported with positional changes,
1.) Facial Paralysis intravenous fluids or vasopressors
2.) Crossed eyes
3.) Muscular weakness
4.) Temporary Blindness THE MEDICAL CONDITIONS MOST LIKELY TO CAUSE
And other unexpected complications. EMERGENCY SITUATIONS IN THE DENTAL OFFICE
They have to be diagnosed according to the ARE:
symptoms manifested.
1. Cardiovascular condtions
Medical Emergencies in the Dental Office a. Atherosclerotic heart disease
a.1 Angina Pectoris
● Even without giving the accurate diagnosis,
a.2 Coronary artery occlusion
a dentist should be able to give the
b. Pending or acute congestive heart
essential treatment for a medical
failure
emergency until the services of a physician
c. Cardiac Arrhythmias
can be secured.
d. Hypertension
Initial Treatment is important e. Hypotension
f. Shock
- A dentist is expected to able to safeguard 2. Respiratory Conditions
the life and welfare of the patient during an a. Asthma
emergency, which can and often does occur b. Emphysema
in the office. c. Mechanical respiratory
embarrassment
Pretreatment Physical Evaluation
3. Nervous System Disorders
- A procedure done before an operation or a. Epilepsy
treatment so that dentist can be forewarn a.1 Grand mal seizures
 a.2 Petit mal seizures e. Thyroid extract (hypothyroidism)
b. Cerebral vascular accidents f. Steroid Hormones ( adrenal
c. Syncope insufficiency)
4. Metabolic Diseases g. Antihypertensive drugs (hypertension)
a. Diabetes h. Anticonvulsive drug ( convulsive
a.1 Diabetic coma disorders)
a.2 Insulin Shock i. Antiarrhythmic drugs (cardiac
b. Cholinesterase Inactivity arrhythmias)
5. Endocrine Malfunction
a. Hypothyroidism
b. Hyperthyroidism
c. Adrenal Insufficiency
6. Hemorrhagic Tendencies
a. Leukemia
b. Hemophilia
c. Thrombocytopenic Purpura
7. Prescribed Medications
a. Antihyperglycemics drugs (diabetes)
b. Cardiac glycosides (congestive failure,
cardiac arrhythmias)
c. Anticoagulants (myocardial infarcts,
phlebitis)
d. Psychosedatives ( anxiety state)

MOST COMMON MEDICAL CONDITIONS THAT MAY OCCUR IN THE DENTAL OFFICE

Cardiovascular conditions

Cardiovascular condition Signs and Symptoms Treatment/Management

Angina Pectoris - Localized: Pain - 2 nitroglycerin tablets (0.6mg) – sublingually

radiating to the arms, - Broken ampuleof amyl nitrate – Inhalation
shoulder or neck.
Substernal discomfort
- Generalized: Facial or - *if not relieved, possibility of coronaryartery
circumoral pallorwith occlusion –
cold perspiration - Give oxygen, Meripidine (Demerol)
Intravenously
- Morphine

Coronary Artery Occlusion - Substernal Pain - Oxygen administration

- Pain Radiating to: - Place patient in supine position with head
- either or both and thorax elevated
shoulders to arm, - Morphine (8 to 15mg)or Meripidine ( 50 to
 elbows, wrist, fingers 100mg) *depending on the severity
and sometimes neck
and angle of the left
jaw.
- Heart Burn
- Perfuse Perspiration
- Mild discomfort
- weakness

Congestive Heart Failure - Anxious with Extreme - Oxygen Administration while in a semisitting
Apnea position
- Moist Cough - Morphine ( 8 to 10mg) or Meripidine ( 50 to
- Pink tinged sputum 75mg) - Intramuscularly
- Rapid Pulse

Cardiac Arrhythmias, hypotension and - Pain - Oxygen Administration

hypertension - Shortness of breath - Proper Positioning
- Headache - Administration of Narcotic Analgesics
- Dizziness / Syncope

Shock - Syncope - Patient should be position in a Semi-reclining

supine position with thorax and legs elevated

If persisting:
- Intravenous – 5% Dextrose in water or
lactated Ringer’s Solution
- Mephentermine Sulfate (Wyamine) for BP
- Phenylephrine (Neo – Synephrine ) for BP

Respiratory Conditions

Respiratory Condition Signs and Symptoms Treatment / Management

Asthma - Wheezing type of Respiration - Cautiously Administer Oxygen

- Epinephrine (0.3 to 0.5 ml of 1:1000 solution) –
Intramuscularly
*if not effective
- Aminophylline (0.25 to 0.5 gm) intravenously
- Isoproterenol 1:200 solution – inhalation through
nebulizer

Emphysema - Coughing spell - Bronchodilator Sprays (containing Epinephrine

- Asthma-like attack 1:1000 or 1:200 Isoproterenol)
 *Afternoon Appointments

Mechanical Respiratory - Choking Spasm Pharynx:

Embarrassment - Laryngiospasm - Hold the mouth open
- Refrain to swallow or taking deep breath until rapid
inspection of the pharynx
- *if cannot be removed by a suitable instrument ask
to cough forcefully.
Larynx:
- Bring to the nearest hospital as quick as possible
*if obstruction is death imminent – do
Cricothyrotomy – inserting a 13 gauge need or a
tracheotome in the midline through the cricothyroid
membrane.

Nervous System disorders

Nervous System Disorder Signs and Symptoms Treatment / Management

Epilepsy - Loss of consciousness - Maintain Patent Airway

- Involuntary muscle movements - *well padded tongue blade
- Intravenous pentobarbital Sodium
(Nembutal) / Secobarbital Sodium
Grand Mal Convulsions Petit Mal Convulsions (Seconal)
- Succinylchloride (20 to 40 mg) –
- Excessive - Loss of Intravenously
muscular activity consciousness - or double dose in intramuscular
- Loss of
consciousness
- Muscle Rigidity
- Headache
- Vomiting
- Muscle soreness

Cerebral vascular - Weakness - Maintenance of patent Airway

emergencies - Paralysis of extremities - Adequate ventilation of oxygen
- Sudden flaccid paralysis of the side of the
face
- Slurred speech
- Unilateral Headache
Syncope - Fainting - Oxygen Administration

Metabolic Diseases

Metabolic Diseases Signs and Symptoms Treatment / Management

Diabetes Diabetic Coma: Insulin Shock:

If patient is taking small amount of insulin, - Thirsty - Give few lumps of sugar, candy or any
consider for diabetic coma - Nauseous sugared drink
- Short breath - Glucagon Hydrochloride (0.5 to 1mg) –
- Warm dry skin intramuscularly add to 5% to 10%
If large amount are taken, consider for Dextrose solution
Insulin Shock:
Insulin Shock
- Hunger
- Weakness
- Cold perspiration
- Easily Angered / Irritated
- Mentally confused

Cholinesterase Inactivity Toxic reaction from ester type local Barbiturates

anesthetics

Endocrine Malfunctions

Endocrine Malfunction Signs and Symptoms Treatment / Management

Hypothyroidism Myxedema – Cardiac Dysfunction - Prevention / Reducing the prescribed

doses
- Mentally dull
- Use of Nalaxone (narcotic antagonist)
- Drowsy
- Apathetic
- Fatigued

Hyperthyroidism - Thyrotoxicosis - Sedatives

- Nervousness - Cold packs to lower the body
- Tremors temperature
- Excessive perspiration - Oxygen administration
- Inability to tolerate heat
- Elevated Metabolic rate
- Increased Pulse rate
- Early fatigue
 - Emotional Instability
- Tracheal pressure (respiratory
symptoms)

Thyroid Crisis
- Emotional disturbances
- Cardiac Difficulties(angina, congestive
heart failure)

Adrenal Insufficiency - Adrenal Shock - Prevention

- Feeling of weakness - 5% Dextrose in water
- Cold and clammy skin - Lactated Ringer’s Solution
- Hydrocortisone Succinate (Solu-Cortef)
100 to 200 mg –IV
- Dexamethasone (Decadron) 4 to 12mg –
IV
- Phenylephrine (Neo-Synephrine) - IV
- Mephentermine Sulfate (Wyamine) –IV

Hemorrhagic Tendencies Signs and Symptoms Treatment / Management

Usually surgical procedure problems. It may Bleeding / Hemorrhage Bleeding and coagulation time and evaluate
be caused by a coexisting condition such as so that preventive measures can be made.
Leukemia,

Hemophilia

thrombocytopenic purpura

anticoagulant therapy

local pathology

hypertension
EMERGENIES RESULTING FROM PRESCRIBED Thioridazine (Mellaril)
MEDICATIONS Haloperidol (Haldol)
Antihyperglycemics Lithium
Insulin ( regular, NPH, PZI, Lente) Tricyclic Antidepressants
Tolbutamide (Orinase) Amitriptyline (Elavil)
Chlorpropamide (Diabinese) Doxepin (Sinequan)
Cardiac Glycosides Imipramine (Tofranil)
Digoxin Monoamine Oxidase Inhibitors
Digitoxin Pargyline (Eutonyl)
Digitalis leaf Phenelzine (Nardil)
Anticoagulant Tranlycypromine (Parnate)
Warfarin (Coumadin) Diuretics
Psychosedatives (Tranquilizers) Spironalactone (Aldactazide)
Meprobamate (Equaril) Triamterene (Dyazide)
Diazepam (Valium) Acetazolamide (Diamox)
Chlordiazepoxide (Librium)
Chlorpromazine (Throrazine) Cardiopulmonary Resiscitation
Trifluoperazine (Stelazine)
Thiorridazine (Mellaril) Airway
Haloperidol (Haldol)
� The single most important aspect of CPR is
Thyroid Medications
Thyroid Extract the establishment of patient’s airway.
Levothyroxine ( Synthroid)
Liothyronine (Cytomel) � The instant consciousness is lost, the victim
Steroid Hormones loses the ability to maintain the patency of
Prednisone the airway
Hydrocortisone (Solu-Cortef)
Dexamethasone ( Decadron) � This upper airway obstruction may occur in
Antihypertensive spite of adequate function of the muscle of
Hydrochlorothiazide ( HydroDIURIL) respiration. However, without patent
Methyldopa (Aldomet) airway, spontaneous, assisted, or controlled
Reserpine (Serpasil)
ventilation is impossible
Guanethedine (Ismelin)
Catapres (Clonidine)
� Maintenance of life depends on adequate
Anticonvulsants
Diphenylhydantoin (Dilantin) exhchange between lungs and the
Phenobarbital atmosphere or its substitute
Primidone (Mysoline)
Antiarrhythmics � Results to hypoxia and hypercarbia
Quinidine
Procaine Amide (Pronestyl) Management
Propranolol (Inderal)
1. Patent airway maintenance is achieved by
Diphenylhydantoin (Phenytoin)
Coronary Vasodilators tilting the victim’s head backward (HEAD
Isosorbide Dinitrate (Isordil) EXTENSTION) to its fullest
Nitroglycerine
Antihistamine 2. The neck should be arched, extension
Chlorpheniramine (Ornade) occurs by rotation of the atlanto-occipital
Diphenhydramine (Benadryl) junction. This maneuver (aka jaw thrust
Promethazine (Phenergan) maneuver/ Chin-lift/Head-tilt maneuver)
Antipsychotics
Chlorpromazine (Thorazine)
 behind or by lifting the chin while tipping and upward direction (aka Heimlich
the head backward. maneuver)

� Stand behind the victim with arms

wrapped around the victim’s waist

� One fist is grasped with the other

hand with the thumb side of the
fist in firm contact with the victim’s
upper abdomen

Triple airway maneuver � Four inward and upward thrusts

should follow in rapid sequence
1. Maximum head extension
� This maneuver increases
2. Protrusion of the mandible to the point of
intrapulmonary pressure,
subluxating it if necessary
stimulating a cough using the air
3. Slight opening of the mouth remaining in the lungs.

**These manueavers all lift the tongue away Breathing

from the posterior pharyngeal wall allowing � Oxygen or air may be forced into the
release from the mechanical obstruction cause patient’s lungs by ambu bag, anesthetic
by relaxation of soft tissue in the upper airway
machine or mouth to mouth or mouth to
� Oropharyngeal and nasopharygeal airways nose breathing
may be inserted to assist in the
� Ambu bag- a manual resuscitator or self-
establishment of patent airway used in
inflating bag, a hand held device commonly
conjunction with the head extension
used to provide positive pressure
� When head extension can’t be done (i.e ventilation
cervical trauma) patent airway may be
� Mouth-to-mouth ventilation- patient’s head
established by mandibular protrusion alone
is tilted backwards to ensure patent airway,
� The tongue may be grasped and protruded and the nose is compressed between the
with a 2x2 piece of gauze held between the thumb and forefinger to prevent air leakage
fingers, a haemostat or other instrument

Airway obstruction cause by inhalation of a

foreign body:

1. Apply four blows in rapid succession with

the clenched fist to the victim’s back
between the shoulder blades

� Each blow should be delivered with

the intention of dislodging the
object

2. If it failed, four manual thrusts should be

delivered to the epigastric area in an inward
 � Absence of pulse indicate the need
for CPR

❑ Blood pressure may be supported by proper

positional change to ensure adequate
venous return, coupled with administration
of intravenous fluids and vasopressors are
required.

❑ For external chest compression, the victim

Mouth to mouth ventilation is positioned lying on a firm surface
1. Operator then open his mouth wide enough horizontally on his back
to cover the patient’s mouth
� Blood flow to the brain is reduced
� A piece of gauze or handkerchief or completely prevented by gravity
can be placed over the patient’s with any elevation of the head
mouth if reluctant to make contact above the heart.

2. He should take a deep inspiration before ❑ With the clinician postioned at the right
each expiration into the patient’s mouth side of the victim, the lower margin of the
rib cage is located with the middle and
3. Determine if the air is reaching the patient’s index fingers of the hand closest to the
lungs by observing the rise and fall of the victim’s feet.
chest wall
❑ The fingers then run along the rib cage
4. Lung inflation is provided once every 5 toward the midline to locate the inferior
seconds border of the

5. When respiratory arrest is presumed to ❑ The heel of the second hands is placed in
have been present, four full-lung inflations the midline on the lower portion of the
should be provided without allowing for full sternum two finger widths superior to its
exhalation inferior border

Circulation ❑ The heel of this hand should be paced on

the long axis of the sternum with the fingers
❑ Palpate the carotid pulse in the neck
elevated away from the chest wall.
❑ While head extension is maintained with
❑ The first hand is then placed on top of the
one hand, the other hand locates the
hand of the sternum
victim’s larynx. The fingers are then moved
laterally to the groove between the trachea ❑ The operator’s elbows are straightened and
and the muscles at the side of the neck the shoulders positioned directly over the
where the carotid pulse can be felt hands.

� A weak pulse may indicate ❑ For a normal sized adult, sufficient pressure
circulatory system depression and must be applied to depress the sternum 4
not collapse to 5 cm (1 ½ ~2 inches)
� This procedure compresses the heart
between the sternum and vertebral column
forcing blood from it into the systemic
circulation

� Pressure is then released allowing heart to

refill

� The time allowed for release should equal

the time required for compression

� During release the hands must remain in

proper contact with the sternum in
preparations for the next compression

� The hands should not be allowed to bounce

free from the sternum

� When one rescuer is present artificial

ventilation and circulation is 15:2 ratio

� If after1~2 minutes of external cardiac

compression and artificial ventilation a
spontaneous pulse is not felt, epinephrine,
1mg ( 1ml of 1:1000) is given intravenously

� Sodium bicarbonate (3~4 gm of 7.5%

solution) should be given as soon as
possible after cardiac arrest to combat the
existing and rapidly increasing acidosis

� Ventricular fibrillation is given if a

spontaneous pulse is not felt after the
administration of proper resuscitative
procedures, plus epinephrine and sodium
bicarbonate

� Victim should be transported to a hospital

for further definitive treatment

Reference:

Monheim’s Local Anesthesia and Pain Control in

Dental Practice – C. Richard Bennett 7th Edition