1. General approach to any emergency
   • Prevention, emergency preparedness, primary survey, ABCDE, basic life support, referral and documentation.
2. Common emergencies in the dental chair
   • Syncope, hypoglycaemia, asthma, angina/myocardial infarction, anaphylaxis, seizures, hyperventilation and aspiration.
3. OMFS-specific surgical emergencies
   • Airway obstruction, severe bleeding, local-anaesthetic toxicity, postoperative haemorrhage, infection with airway compromise, and complications of sedation.
4. Drugs and emergency kit
   • Oxygen, adrenaline, glucose, salbutamol, nitroglycerin, aspirin, antihistamine, hydrocortisone, midazolam, and their indications.

Medical Emergencies in Oral and Maxillofacial Surgery

25-mark answer

Introduction

1. Prevention and preparedness

A. Preoperative prevention

1. Take a thorough and updated medical history:
   • Previous syncope or seizures
   • Diabetes and timing of meals/insulin
   • Asthma/COPD
   • Ischaemic heart disease, hypertension, arrhythmias
   • Allergy to drugs, latex, antibiotics or local anaesthetics
   • Anticoagulants/antiplatelets and bleeding disorders
   • Epilepsy
   • Pregnancy
   • Current medications and substance use
2. Assess risk and defer elective treatment if the patient has:
   • Unstable angina
   • Recent myocardial infarction
   • Uncontrolled asthma
   • Poorly controlled diabetes
   • Severe hypertension
   • Acute spreading odontogenic infection with airway risk
3. Reduce anxiety:
   • Explain the procedure.
   • Use short appointments.
   • Ensure adequate analgesia.
   • Avoid prolonged fasting, especially in diabetics.
   • Use conscious sedation only with appropriate monitoring and trained personnel.
4. Check emergency drugs, oxygen delivery, suction, airway adjuncts and AED daily or according to local protocol. Dental emergency guidance also emphasizes periodic review of expiry dates and audit of emergency stock. Dental-practice emergency guidance

B. Essential emergency equipment

• Oxygen cylinder with mask and tubing
• Suction apparatus
• Bag-valve-mask device
• Oropharyngeal and nasopharyngeal airways
• AED
• Pulse oximeter, blood pressure monitor and glucose meter
• Emergency drugs, according to local/national protocol:
  • Adrenaline
  • Salbutamol inhaler
  • Glyceryl trinitrate
  • Aspirin
  • Oral glucose and glucagon where indicated
  • Midazolam for prolonged seizures
  • Antihistamine and corticosteroid as adjuncts
  • Naloxone if opioids/sedation are used
  • Intravenous lipid emulsion where local-anaesthetic systemic toxicity is a foreseeable risk

2. Universal management of any emergency

Flowchart 1: Initial response

PATIENT BECOMES UNWELL
          ↓
STOP DENTAL/ORAL SURGICAL TREATMENT
Remove instruments, suction blood/debris, make area safe
          ↓
CALL FOR HELP
Alert team and bring emergency kit, oxygen and AED
          ↓
POSITION PATIENT APPROPRIATELY
Supine with legs raised for syncope/hypotension
Upright for breathing difficulty
Recovery position if unconscious but breathing
          ↓
ASSESS ABCDE
A - Airway
B - Breathing
C - Circulation
D - Disability: consciousness, glucose, seizures
E - Exposure: rash, bleeding, swelling, temperature
          ↓
GIVE OXYGEN IF HYPOXIC OR SERIOUSLY UNWELL
Monitor pulse, BP, respiratory rate, SpO2
          ↓
TREAT THE SPECIFIC CONDITION
          ↓
CALL EMERGENCY MEDICAL SERVICES EARLY
Transfer if symptoms persist, are severe, or diagnosis is uncertain
          ↓
DOCUMENT, DEBRIEF, RESTOCK AND REFER

ABCDE approach

3. Common medical emergencies in OMFS

A. Vasovagal syncope

Features

Management flowchart

PRESYNCOPE / LOSS OF CONSCIOUSNESS
          ↓
STOP TREATMENT + REMOVE INSTRUMENTS
          ↓
LAY PATIENT SUPINE AND RAISE LEGS
          ↓
MAINTAIN AIRWAY + LOOSEN TIGHT CLOTHING
          ↓
OXYGEN IF REQUIRED + CHECK VITAL SIGNS
          ↓
RECOVERY WITHIN 1-2 MINUTES?
     ↓ Yes                         ↓ No / atypical signs
Observe, reassure,              Consider hypoglycaemia,
give oral fluids when           arrhythmia, seizure, MI or stroke
fully alert                     → call emergency services

B. Hypoglycaemia

Causes

• Missed meals
• Excess insulin or oral hypoglycaemic drugs
• Anxiety and prolonged appointment
• Vomiting or strenuous activity

Features

Management

SUSPECT HYPOGLYCAEMIA
          ↓
CHECK CAPILLARY BLOOD GLUCOSE IF AVAILABLE
          ↓
CONSCIOUS AND ABLE TO SWALLOW?
     ↓ Yes                                  ↓ No / seizure / unconscious
Give fast-acting oral glucose               Call emergency services
(e.g., glucose gel/tablets or               Maintain airway and recovery position
sugary drink)                               Do NOT give oral intake
          ↓                                  ↓
Recheck after 10-15 min                     Give glucagon if trained,
          ↓                                  available and locally indicated
Give longer-acting carbohydrate              Monitor ABCDE
before discharge

C. Asthma and acute bronchospasm

Features

• Breathlessness
• Wheeze
• Cough
• Chest tightness
• Difficulty speaking in full sentences
• Cyanosis, exhaustion or silent chest in severe attacks

Management

ACUTE ASTHMA / WHEEZING
          ↓
STOP TREATMENT
SIT PATIENT UPRIGHT
          ↓
GIVE SALBUTAMOL VIA INHALER + SPACER
Use patient's inhaler if available
          ↓
GIVE OXYGEN AND MONITOR SpO2
          ↓
IMPROVES PROMPTLY?
     ↓ Yes                        ↓ No / severe signs
Observe and arrange review       Call emergency services
                                 Repeat bronchodilator as per protocol
                                 Prepare for respiratory arrest

D. Anaphylaxis

Causes in OMFS

• Antibiotics
• Latex
• Chlorhexidine
• Analgesics/NSAIDs
• Sedation drugs
• Rarely, local anaesthetic components or preservatives

Recognition

• Airway: throat tightness, hoarse voice, tongue/lip swelling, stridor
• Breathing: wheeze, persistent cough, respiratory distress
• Circulation: hypotension, collapse, tachycardia
• Skin: urticaria, flushing, itching, facial swelling

Management flowchart

SUSPECTED ANAPHYLAXIS
Airway/breathing/circulation problem ± rash
          ↓
STOP SUSPECTED TRIGGER
CALL EMERGENCY SERVICES IMMEDIATELY
          ↓
LAY FLAT WITH LEGS RAISED
If severe breathing difficulty: allow sitting with legs outstretched
Do NOT allow standing or walking
          ↓
GIVE INTRAMUSCULAR ADRENALINE
Adult: 500 micrograms IM in anterolateral thigh
          ↓
HIGH-FLOW OXYGEN + ABCDE + MONITORING
          ↓
NO IMPROVEMENT AFTER 5 MINUTES?
          ↓
REPEAT IM ADRENALINE
          ↓
URGENT HOSPITAL TRANSFER AND OBSERVATION

E. Angina and suspected myocardial infarction

Angina

CHEST PAIN IN DENTAL CHAIR
          ↓
STOP PROCEDURE + SIT COMFORTABLY
          ↓
GIVE PATIENT'S GLYCERYL TRINITRATE
          ↓
PAIN RESOLVES RAPIDLY AND MATCHES KNOWN ANGINA?
     ↓ Yes                               ↓ No / first episode / severe pain
Observe and arrange medical review       Suspect acute coronary syndrome
                                         Call emergency services
                                         Give aspirin if not allergic/
                                         contraindicated and per protocol
                                         Monitor and prepare AED

Suspected myocardial infarction

F. Cardiac arrest

Recognition

• Unresponsive
• Not breathing normally, or only agonal gasps

Management flowchart

UNRESPONSIVE PATIENT
          ↓
SHOUT FOR HELP AND CALL EMERGENCY SERVICES
          ↓
OPEN AIRWAY AND ASSESS BREATHING
          ↓
NOT BREATHING NORMALLY
          ↓
START CPR: 30 COMPRESSIONS : 2 BREATHS
          ↓
ATTACH AED AS SOON AS AVAILABLE
          ↓
FOLLOW AED VOICE PROMPTS
Continue CPR with minimal interruption
          ↓
HAND OVER TO AMBULANCE/RESUSCITATION TEAM

G. Seizures

Causes

Management

SEIZURE OCCURS
          ↓
STOP TREATMENT
REMOVE INSTRUMENTS AND SHARP OBJECTS
          ↓
PROTECT FROM INJURY
Do not restrain and do not place objects in mouth
          ↓
TIME THE SEIZURE
Maintain airway when safe
          ↓
AFTER CONVULSIONS STOP
Recovery position + oxygen if needed
Check glucose and monitor
          ↓
CALL EMERGENCY SERVICES IF:
- seizure lasts ≥5 minutes
- repeated seizures occur without recovery
- first seizure
- injury, pregnancy, diabetes or breathing difficulty
- delayed recovery

H. Airway obstruction and aspiration

Prevention

• Use throat packs when indicated.
• Use gauze barriers and high-volume suction.
• Secure small components with floss where appropriate.
• Keep the patient in a safe position.
• Count gauze swabs before and after procedures.

Management flowchart

SUSPECTED FOREIGN-BODY AIRWAY OBSTRUCTION
          ↓
CAN THE PATIENT COUGH, SPEAK AND BREATHE?
     ↓ Yes                                  ↓ No
Encourage coughing                         Call emergency services
Monitor closely                             Give back blows and abdominal
                                           thrusts/chest thrusts as appropriate
          ↓                                 ↓
Deterioration?                              Becomes unconscious?
Call emergency services                     Start CPR and inspect mouth
                                            for visible object between cycles

I. Local-anaesthetic systemic toxicity (LAST)

Causes

• Accidental intravascular injection
• Excess total dose
• Rapid absorption from vascular tissue
• Small body size, hepatic dysfunction or cardiac disease

Early symptoms

• Perioral numbness
• Metallic taste
• Tinnitus
• Dizziness
• Agitation
• Slurred speech
• Tremor

Severe toxicity

• Seizures
• Hypotension
• Bradyarrhythmias or ventricular arrhythmias
• Cardiovascular collapse

Management

SUSPECT LOCAL-ANAESTHETIC TOXICITY
          ↓
STOP INJECTION IMMEDIATELY
          ↓
CALL FOR HELP / EMERGENCY SERVICES
          ↓
ABCDE + HIGH-FLOW OXYGEN
Support ventilation and circulation
          ↓
SEIZURE?
Protect airway; benzodiazepine if trained
          ↓
CARDIOVASCULAR INSTABILITY?
Begin resuscitation and use lipid-emulsion
therapy according to local anaesthetic toxicity protocol
          ↓
URGENT HOSPITAL TRANSFER

J. Excessive haemorrhage

Causes in OMFS

• Surgical trauma
• Anticoagulants or antiplatelet therapy
• Coagulopathy, liver disease or thrombocytopenia
• Hypertension
• Failure of local haemostatic measures
• Postoperative infection or disturbed clot

Management flowchart

POSTOPERATIVE OR INTRAOPERATIVE BLEEDING
          ↓
ASSESS ABCDE AND ESTIMATE SEVERITY
          ↓
SUCTION AND IDENTIFY BLEEDING SITE
          ↓
DIRECT PRESSURE WITH GAUZE PACK
          ↓
LOCAL MEASURES
Sutures, haemostatic dressing, local vasoconstrictor
where appropriate, compression and tranexamic-acid protocol
          ↓
PERSISTENT / BRISK BLEEDING OR HAEMODYNAMIC INSTABILITY?
          ↓
CALL EMERGENCY SERVICES / URGENT HOSPITAL REFERRAL
Check medications and coagulation history

K. Acute spreading odontogenic infection with airway compromise

Red flags

• Trismus
• Dysphagia or odynophagia
• Drooling
• Voice change or “hot potato” voice
• Tongue elevation
• Floor-of-mouth swelling
• Stridor
• Tachypnoea, hypoxia or toxic appearance

Management

SUSPECT DEEP SPACE INFECTION / AIRWAY THREAT
          ↓
DO NOT LIE PATIENT FLAT
KEEP UPRIGHT
          ↓
CALL SENIOR OMFS, ANAESTHESIA AND EMERGENCY TEAM
          ↓
ABCDE + OXYGEN + MONITORING
Avoid repeated oral examination or unnecessary manipulation
          ↓
URGENT HOSPITAL ADMISSION
Definitive airway plan + IV antibiotics + surgical drainage as indicated

4. Emergency drugs: summary

5. Post-emergency actions

1. Do not resume elective treatment on the same day.
2. Transfer to hospital when indicated.
3. Record:
   • Time and nature of event
   • Vital signs and glucose readings
   • Drugs, doses, route and time given
   • Names of staff involved
   • Communication with ambulance service and relatives
4. Complete an incident report.
5. Restock emergency drugs and equipment.
6. Conduct a team debrief and identify preventive measures.
7. Arrange medical or specialist follow-up.

Conclusion