Emergency care in dental practice 1983
Purpose of emergency care 1. to preserve vital function ( respiration and circulation) 2. to prepare the patient for transportation Measures of emrgency care 1. maintaintenance of patent airway 2. temporary cessation of hemorrhage 3. provision of blood fluid repalcement to support circulation Maintenance of patent airway 1. oral cavity muust be cleared of blood coagula and vomitus 2. denture & severely loosened teeth should be removed. 3. patient must be placed in the stable left sided lateral position 4 oropharyngeal or nasopharyngeal tube; bilateral mid-msndibulsr fracture presence of hematoma severe lingual swelling 5. extend the tongue with safety pin in the crushing fracture Temporary hemostasis 1. placement of immobilizing external bandage 2. in the extensive soft tissue injury, wound edges are approximated as well as possible and maintained in position with external bandage 3. external bandage Funda maxilla(photo) barrel bandage; to prevent further displacement(photo) to enhance hemostasis and analgesia spatula dressing; fixation of maxilla against the base of skull 4. When hemmorrhage from larger arteries, only digital pressure will be used. Emergency splinting(photo) Indications 1. if individual fragments are greatly displaced and mobile 2. severe fracture pain 3. increased danger of hemmorrhage and infection Temporary immobilization 1. external; bandage 2. plaster head chin cap 3. rubber chin sling Internal wire ligature 1. Gilmer's direct wiring 2. Kazanjian button 3. eyelet method 4. Ernst ligature Blood replacement when shock symptom are present or threatened Emergency care of soft tissue After all, bone must be reduced and immobilized simultaneously 1. hemostasis 2. gentle cleansing 3. debridement 4. removal of foreign bodies 5. temporal aditional suture with atraumatic needle 6. antibiotic prophylacsis 7. tetanus prophylaxis Emergency care in anesthesia 1. vasodepressor syncope 2. hyperventilation syndrome 3. systemic toxisity Vasodepressor syncope clinical feature 1. sweating 2. pallor 3. nausea 4. rolling eyes 5. dizziness 6. tremor 7. unconsciousness predisposing faactors 1. psychogenic fright, anxiety, emotional stress pain( sudden & unexopected) sight of blood or surgical instrument 2. non-psychogenic sitting in an uprighting position or standing hunger exhaustion poor physical condition hot, humid crowed condition pathophysiology 1. presyncope stress(emotional or sensory) catecholamine secretion into blood decrease in peripheral vascular resistance increase in blood flow to many tissue(muscle) pooling of blood in the muscle decrease in circulating bloos volume drop in arterial blood pressure decrease in cerebral blood flow reflex bradycardia( below 50/min) decrease in cardiac output decrease in blood pressure cerebral ischemia loss of consciousness 2. syncope To maintain the consciousness, 30ml of blood per 100g of brain per minute will be required( critical level) Normal value of cerebral blood flow;50-55ml of blood per 100g of brain/minute average weight of brain; 1360g 3. recovery(tx) reclined or semireclined position having the patient breath deeply and slowly divert the patient's attention briskely tapping a foot to facilitate venous return to heart and increse blood flows to brain( above critical level for consciousness) Systemic toxicity etiology 1. true overdose 2. temporary overdose cause by an intravenous injection clinical features 1. dizziness 2. palpitation 3. headache 4. feeling of flying apart prevention 1. aspiration 2. slow injection treatment no specific therapy Hyperventilation syndrome definition a state in which there is an increased amount of air entering pulmonary alveoli; resuulting in a reduction of carbon dioxide tension to subnormal level( 40mmhg) predisposing factor 1. presence of acute anxiety 2. most in woman 3. from 15 years to 40 years of age sign & symptoms 1. tightness in chest and suffocation 2. light headedness and giddiness 3. palpitation 4. epigastric discomfort 5. globus hystericus 6. tingling or paresthesia of hands , feet and perioral region 7. muscular twitching 8. loss of unconsciousness vital sign B.P. ↑ pulse rate↑ respiratory rate↑ deeper or more shallow respiration pathophysiology 1. anxiety 2. increased blood catecholamine level 3. excessive blowing of co2 4. elevation of blood PH 5. decrease in level of ionized calcium 6. respiratory alkalosis management to reduce anxiety and to resstore chemical balaance of blood a. anxiety reduction 1. terminate dental procedure 2. position patient in any comfortable position 3. remove foreign material from mouth� 4. calm patient( iatrosedation) a. correct respiratory alkalosis 5. breath co₂-enriched air through brown paper bag, full face mask or hands cupped over face 6. diazepam( valium) 7. follow-up determine cause of anxiety; treat anxiety through psychosedation Emergency care in acute infection spread of infection a. factors relating to organism 1. number of bacteria invading tissues 2. virulence of invading bacteria 3. enzyme; hyaluronidase(streptococcus) fibrinoysin(streptococcus) coagulase(staphylococci) b. factors related to the host 1. general bodily resistance to disease age debilitating disease immunity undernourished vitamin deficiency 2. site of entry of the infecting organism physical nature of involved tissue content of histiocyte and lymphocyte flow of tissuee fluid and lymph 3. anatomical factors muscle; buccinator m. mylohyoid m. planes of fascia diagnosis 1. flushed, dry and hot skin elevation of B.T., pulse, respiration rate 2. pale, cold and clammy skin normal or subnormal B.T. dull pt's eye poor resistance to infection general medical history helth resistance to infection cause,location,extent,type,stage of infection treatment a. general measures bed rest soft diet( daily fluid intake at least 3litre) antibiotic therapy b. local measure drainage of pus removal of cause I & D( Hilton's method) intraoral incision through mucous membrane only parallel to surface of alveolar bnone sinus forceps localization use of hot saline mout-baths use of heat to facial skin use of short wave diathermy local cold application 1. diminution of capillary blood flow 2. number of open capillaries is decreased. 3. tissue metabolism is reduced 4. normal rate of exchange between blood & tissue is decreased. heat therapy 1. vasomotor reflex 2. number of open capillaries 3. tissue metabolism 4. peripheral vasodilation 5. capillary blood pressure 6. attraction of lymph, plasma and tissue fluids acute infection periapical absccess pericoronal absecc periodontal abscess submandibular space abscess infraorbital space abscess 1. periapical abscess result of nonvital or degenerative pulp pain, swelling, systemic reaction Tx. localization of abscess antibiotic therapy I & D removal of cause carious infection pulpal infection through trauma mechanical, chemical, thermal injury 2. pericoronal infection sx. submandibular adenitis trismus pain in the region general condition of malaise moderate elevation of body temperature difficult swallowing tendernes to palpation Tx. dilation of aperture of entrance with probe drain insertion analgesics warm saline mouth baths antibiotic therapy extraction upper 3rd molar 3. periodontal abscess chronic periodontitis sudden onset extreme pain periosteal and mucosal expansion tx.. I &D 4. abscess of base of the lip cause: peripheral infection of upper anterior teeth sx. edematous swelling obstruction of nasolabial fold tx. I&D chamber opening 5. infraorbital space abscess cause; periapical infection of upper canine and premolar sx. periorbital swelling obstruction of nasolabial fold tenderness to palpation swekking on the lip redness 6. submand. space abscess 7. Ludwig's angina overwhelming, generalized septic cellulitis of the submandibular region sx. brawny indulation bilateral 3 fascial space( submandibular, sbmental, sublinual) typical mouth opening appearance tx. massive antibiotics if needed, tracheostomy medially incision [parallel to inferior border of mandible general management 1. to destroy or inhibit bacterial growth 2. to encourage the physiologic defence mechanism Tracheostomy primary technic to be employed for the relief of sudden airway embarrassment surgical procedure for the long term airway maintenance Criothyrotomy 1. criothyroid membrane puncture 2. more easily and quickly than tracheostomy 3. incision or puncture with 17G needle
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