Additional Emergency Situations

Cerebrovascular accident (CVA, stroke, cerebral apoplexy) is the destruction of brain tissue as a result of intracerebral hemorrhage that can result from a ruptured blood vessel, thrombosis, embolism, or vascular insufficiency. CVA is most common in males aged 60 - 69 years, except for embolism, which commonly occurs from 20 to 70 years of age, usually after age 40. A transient ischemic attack (TIA) is a mini-stroke," or a "temporary stroke" during which signs and symptoms usually last less than eight hours, while some last only 15-60 minutes and others less than 24 hours and may signal impending stroke. Intracranial hemorrhage accounts for about 10% of all CVAs, but has the highest mortality rate. Intracranial hemorrhage is usually caused by rupture of an arterial aneurysm.

Sudden unilateral weakness and numbness, or paralysis of the face, arm, or leg are primary symptoms of stroke. The victim may have difficulty speaking or being understood when speaking. Difficulty breathing and swallowing, loss of bowel or bladder control, blurred or dimmed vision with the pupils of the eyes being of unequal size also may be signs. Clinical manifestations of CVA due to hemorrhage also may include a sudden violent headache, nausea and vomiting, chills and sweating, dizziness, and vertigo that may progress to unconsciousness. Unconsciousness in a stroke victim is associated with a grim prognosis with a very high mortality rate.

EMS should be called immediately, vital signs monitored, oxygen administered, and BLS provided, as indicated by the patient's condition. The unconscious CVA victim should be positioned in the supine position. If the blood pressure is markedly elevated, the head and chest should be elevated slightly. If available and possible, an IV line should be established using 5% dextrose solution. TIA, symptoms may be gone by the time EMS arrives, but the person may be hospitalized or should at least seek medical attention, especially if there has been no previous history of CVA.

Previously, stroke almost always resulted in irreversible brain damage but new drugs and treatments can now limit the damage. Most treatments for stroke are time sensitive, so it is critical that EMS be summoned as soon as stroke is suspected.

Seizure, a sudden episode of uncontrolled electrical activity in the brain, can be caused by injury, disease, fever (especially in young children), infection, poisoning or often for unknown reasons. When irregular electrical activity of the brain occurs, a sudden discharge of electrical energy can result. A seizure can be described as an episode of altered consciousness, motor activity, and/or sensory phenomena. The area of the brain where the aberration occurs determines the type of seizure experienced. The symptoms of a seizure may be as benign as a momentary break in the stream of thought and activity or may include tingling or twitching of an area of the body, and perhaps hallucinations, intense fear, or feelings of déjà vu. If overstimulation of brain nerve cells continues and spreads throughout the brain, the individual may lose consciousness and progress to bilateral jerks of the extremities, involuntary sustained muscular contraction (tonic convulsions) and alternating contraction and relaxation of muscles (clonic convulsions).

Epilepsy is a condition affecting over a million U.S. citizens in which convulsive seizures are recurrent, although not all recurrent convulsions are due to epilepsy. Symptoms can vary from almost imperceptible to the dramatic loss of consciousness followed by paroxysms of tonic-clonic seizures. Sometimes before a seizure, the person experiences an aura, which can be an unusual sensation, feeling, sound, smell, or urgent need for safety. At one time it was believed that the aura was a warning of impending seizure. However, currently the aura is thought to actually be a part of the seizure. In epilepsy, the aura can serve as a warning of impending attack and may give the patient time to lie down.

Though to a bystander seizures may seem to last a long time, most actually only last from about one to three minutes. Breathing may become irregular or even temporarily stop. The eyes may roll back until only the whites show and the body may become perfectly rigid. Fecal and urinary incontinence is not uncommon. More severe seizures may cause the victim to experience sudden and uncontrollable tonic-clonic muscular contractions that can last several minutes.

Emergency care of the person experiencing a seizure, regardless of the cause or degree of the symptoms, is to protect the victim from harm and maintain the airway should that action become necessary. Attempts to stop the seizure by restraining the individual should not be made. Likewise no attempt should be made to wedge the mouth open to prevent the victim from biting the tongue, which is rare, or "swallowing the tongue", which is impossible. Either of these actions may cause unnecessary injury to both the victim and/or to the person attempting to help. Objects in the vicinity that might cause injury should be removed to protect the person from harm. After the seizure is over, the victim should be positioned on the side to help blood and other fluids drain. The individual may be drowsy and disoriented when the seizure is over and needs to rest. Abnormal breathing sometimes experienced during the seizure will return to normal. The victim should be examined and treated for non-life-threatening injuries incurred during the seizure. Privacy and reassurance should be given. A tonic-clonic seizure is dramatic, but generally self-limiting. According to the American Red Cross, EMS does not normally need to be summoned, except when:

• seizures occur repeatedly;
• a seizure lasts longer than five minutes;
• the victim appears injured;
• the victim has no history of epilepsy that could have brought on the episode;
• the victim is pregnant;
• the victim is an infant or child experiencing his first febrile seizure;
• the victim is diabetic; or
• the victim does not regain consciousness immediately after the seizure.

Diabetic emergencies are the result of diabetes mellitus, a chronic disorder of carbohydrate metabolism in which insufficient insulin is produced or insulin is not used effectively. Insulin, the hormone produced in the pancreas, helps to regulate the amount of circulating glucose in the blood. Since cells receive nutrition from glucose, without the proper balance of sugar and insulin, they can be damaged or starve and the body will not be able to maintain homeostasis. Diabetes is marked by hyperglycemia (excess glucose in the blood) and glycosuria. Diabetes mellitus affects approximately five million people in the U.S., with about 80% over 45 years of age. The emergency conditions associated with diabetes include hypoglycemia, the most acutely life-threatening, and the slower onset hyperglycemia.

Type I, insulin - dependent diabetes mellitus (IDDM), represents about five percent of all cases of diabetes. It is more common in adolescents, but can occur in adults, especially if it occurs in a non-obese person or late in life. In this form virtually no insulin is produced. Type II, non-insulin-dependent diabetes mellitus (NIDDM) is mostly seen in adults but may occur in some children. In NIDDM, circulating endogenous insulin blood levels are present, but may be in lower than normal or inadequate amounts during times of increased need. Persons with NIDDM do not require exogenous insulin therapy.

Hyperglycemia, a medical emergency of diabetes mellitus, is precipitated by factors that increase the body's need for insulin. Hyperglycemia is not acutely life threatening, but if uncorrected may lead to diabetic ketoacidosis and coma; life-threatening conditions. The most common causes of these emergency conditions are ignorance about the disease or neglect of therapy. Dental therapy is a potential threat since stress increases insulin needs, which in turn can precipitate hyperglycemia even in a person who is normally well controlled. Also, simply having a dental appointment may cause the person to alter normal eating habits that could create an insulin imbalance. Malamed suggests that after extensive dental treatment, the patient should be instructed to check blood glucose levels at least four times a day for several days, and make dosage adjustments. If there are questions either from the oral health care professional or the patient, the physician should be consulted.3

Clinical manifestations of hyperglycemia depend on the severity of the condition and the length of time the patient has had the disease. The classic trio of "polys", polydipsia (excessive thirst), polyphagia (excessive hunger), and polyuria (excessive urination), especially with marked weight loss may have been evident for a day or two before the hyperglycemic episode. Some other possible symptoms include itching, frequently about the genitals, marked fatigue, weight loss, headache, blurred vision, abdominal pain, constipation, nausea and vomiting, dyspnea, and mental stupor. Over time, if diabetic hyperglycemia is not treated, the person can progress to physical weakness, fruity-sweet acetone breath, florid (bright red) face, and hot dry skin. Respiration is deep and rapid, tachycardia and hypotension are noted, diabetic coma may ensue and permanent disability or death may result.

Management of the conscious possibly hyperglycemic patient consists of recognizing the condition and referring the patient to a physician for evaluation and treatment. No dental therapy should be performed while diabetic hyperglycemia is suspected. EMS should be called immediately for the unconscious patient. The patient should be placed in the supine position and basic life support begun.

Hypoglycemia, usually a result of exogenous insulin therapy, is an acute life-threatening condition. It can result from an insulin overdosage or failure to maintain normal food intake, usually by delaying or omitting meals. It is generally manifested in patients receiving insulin therapy, but has also been seen in patients treated with oral hypoglycemic agents, although the condition is less acute in such cases. Although somewhat rare, it is also possible in a person who does not have diabetes.

Hypoglycemia is a true immediate life-threatening condition with acute onset and may rapidly progress to loss of consciousness. The first manifestations of hypoglycemia are the result of diminished cerebral function resulting from a lack of nutrition to brain cells. Symptoms include decreased spontaneity of conversation, inability to perform simple calculations, lethargy, incoherence, uncooperativeness, and mood changes. A person experiencing diabetic hypoglycemia is sometimes mistaken as being drunk or on drugs. Other symptoms may include hunger, nausea, increased gastric motility (growling stomach), sweating, tachycardia, piloerection (hair feels as if it is standing on end) and cold and wet skin.

If symptoms are permitted to progress without corrective action, the person may lose consciousness and experience seizures.

Prompt recognition of a diabetes-related emergency is crucial. The most telling differentiation between hyperglycemia and hypoglycemia is that the hyperglycemic person has a hot and dry appearance and acetone odor; the hypoglycemic person has a cold, wet appearance and bizarre behavior.

Malamed emphasizes that any diabetic patient who behaves in a bizarre manner or who loses consciousness should be managed as if he were hypoglycemic until proved otherwise since this condition is an IMMEDIATE THREAT TO LIFE.

A cooperative patient with signs and symptoms of hypoglycemia should be given oral carbohydrates, such as sugar or sugared drink. Recovery is usually rapid and dramatic. When a person does not respond to carbohydrates or will not cooperate, EMS should be called. If available, a parenteral carbohydrate, such as glucagon or IV dextrose solution should be given, the patient monitored, and BLS provided as indicated. For unconscious patients, EMS should be summoned immediately and BLS provided. Definitive management includes the administration of CHO by the most effective method possible, but liquids should never be given.

Myocardial infarction (MI) or heart attack occurs when there is deficient arterial blood supply to a portion of the myocardium resulting in deprivation of oxygen and nutrition to the cells of the heart muscle. The lack of oxygen and nutrition for a long enough period of time can cause cellular necrosis. Angina pectoris occurs when there is a temporary insufficient supply of oxygen to the heart muscle. Angina pectoris and myocardial infarction both cause chest pain. The primary differentiating symptoms are in the type of pain experienced and duration of symptoms.

Mild exercise, stress and/or anxiety increase the demand for oxygen and precipitate episodes of angina pectoris. The victim may describe the pain as a squeezing, as heaviness, or a dull ache that lasts only from one to 10 minutes. A person with angina pain generally has had a previous diagnosis of angina pectoris. These individuals usually carry nitroglycerin to relieve the symptoms of an acute attack by widening the arteries and allowing more blood to flow to the myocardium. Also, ceasing the physical activity or other provoking stimulus to reduce the added need for oxygen to the heart may also shorten the episode. Vital signs are generally normal during an anginal episode.

A person experiencing an anginal episode should be placed in a comfortable position and given their own vasodilator, either nitroglycerin tablet under the tongue, or nitrolingual spray. Oxygen also may be administered. The symptoms should be relieved within two to three minutes. After the episode passes, it is best to let the patient rest before continuing dental treatment or reschedule for another day to continue. If the pain is not relieved, oxygen should be provided and the person assisted in taking a second dose of nitroglycerin. After waiting another two to three minutes, a third dose may be administered if necessary. No more than three sprays or three tablets should be administered within a 15-minute period. If pain is not relieved in the known angina pectoris patient within 10 minutes, the American Heart Association recommends that emergency care be sought immediately.

MI is of longer duration than angina and is characterized by more intense pain. The pain has been described as ranging from discomfort to a crushing substernal pain that can radiate to the shoulder, arm, neck, or jaw. Resting, changing position, or taking nitroglycerin does not relieve the pain. Often the victim has dyspnea, is short of breath, and/or breathes noisily and faster than normal. The skin may be pale, ashen, or cyanotic, and there may be sweating. Some victims may be nauseated and may vomit.

Since MI can lead to cardiac arrest, immediate recognition and action are critical. Once a heart attack victim goes into cardiac arrest, the chances of survival decrease. Most deaths from MI occur within the first two hours after the signs and symptoms occur. EMS should be summoned immediately if there is any reason to suspect heart attack. The person should be assisted to rest as comfortably as possible. Vital signs should be monitored and preparation to give CPR begun, in case the person goes into cardiac arrest.

Anaphylaxis is an acute life-threatening severe allergic reaction. It can result from contact with drugs, foods, or chemicals, or from the bite or sting of insects to which the person is allergic. The symptoms may initially include skin reactions such as swelling, redness, rash, or hives; then progress to respiratory distress from swollen air passages and eventually to life-threatening shock.

The primary response following contact with the allergen should be to observe the person carefully for signs of allergic reaction. At the first sign of respiratory difficulty, EMS should be summoned. The person should be assisted to a position that allows easier breathing and if available, epinephrine should be given. Many severely allergic patients carry their own anaphylaxis emergency kit, but dental facilities should keep epinephrine in the emergency kit. The patient should be monitored and BLS begun as warranted.