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Syncope in dentistry.pptx

This presentation provides an overview of syncope, a common medical emergency in dental practice. Created during my internship, this presentation aims to educate dental students on the causes, symptoms, diagnosis and management of syncope with a focus on dental specific considerations.

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SS Y N C O P E Syncope Kingshika Joylin CRRI’24 For the dept. of oral and maxillofacial surgery Rajas dental college and hospital, Tirunelveli dt. in dentistry.
Definition Transient, self limited loss of consciousness due to acute global impairment of cerebral blood flow. (Harrison) AKA ‘vasovagal syncope’ or ‘vasodepressor syncope’
Causes of transient loss of consciousness • Syncope Reflex syncope/Vasovagal syncope/Neural syncope Orthostatic hypotension Cardiac syncope • Neurological disorders • Psychiatrical disorders • Metabolic disorders
Reflex/Neural mediated Orthostatic hypotension Cardiac • Most common in occurrence • Due to episodic vasodilation & loss of vasoconstrictor tone • Usually a prodrome Transient change in cardiovascular homeostatic reflexes o VASOVAGAL SYNCOPE - orthostatic vasovagal - emotional vasovagal (fear, phobia, pain) o SITUATIONAL SYNCOPE (defecation, swallowing, micturition, coughing) o CAROTID SINUS SYNDROME e.g., tie too tight Chronic impairment in cardiovascular homeostatic reflexes o VOLUME DEPLETION haemorrhage, vomiting, diarrhoea o AUTONOMIC FAILURE - Primary autonomic failure (old age, parkinsonism) - Secondary autonomic failure (diabetes, amyloidosis, spinal cord injuries) - Drug induced (vasodilators, diuretics, anti-depressants) o ARRHYTHMIA (bradyarrhythmia, tachyarrhythmia) o STRUCTURAL DEFECT (aortic stenosis, prosthetic valve dysfunction, MI) o GREAT VESSEL DEFECT (pulmonary embolism, acute aortic dissection) Often feels dizzy when changing position
Pathophysiology Anxiety Catecholamine release Peripheral vascular resistance Pooling of blood in periphery Stimulation of sympathetic nervous system Heart rate Feeling of warmth Rapid breathing Pallor Perspiration Decompensation Reflex vagally mediated Cerebral blood flow SYNCOPE Bradycardia Weakness Nausea Hypotension Arterial blood pressure
Stimulus sent to nuclei of vagus nerve Response sent via parasympathetic nervous system to the heart Cardio inhibitory response: BP Less O2 carried back to brain resulting in ‘SYNCOPE’
X Failure of cerebral blood flow autoregulation leads to global cerebral hypoperfusion Cerebral blood flow normally, 50-60 ml/min/100gm of brain tissue If reduced, 25 ml/min/100gm Impaired consciousness leading to complete if prolonged for 6-8 seconds
Sympathetic vs Parasympathetic Decreased venous return to the heart Normally, this sympathetic stimulation compensates and patient does not faint In other hand, Stress causes strong left ventricular contraction that activates cardiac mechanoreceptors & vagus nerve resulting in vasodilation, decreased heart rate , hypotension leading to syncope Baroreceptors in the carotid sinus and arch of aorta signal to the brain to produce more adrenaline to increase BP &HR
Sudden emotional stress Pain, especially sudden & unexpected Anxiety Sight of blood or surgical or other dental instruments Erect sitting or standing posture Exhaustion Hot, humid, crowded environment Poor physical condition Precipitating factors Fasting Low circulatory volume Poor physical conditions Warm & crowded environment Aggravating factors
Prodromal symptoms E A R L Y L A T E (established syncope) Feeling of warmth Loss of colour: pale or ashen grey skin Diaphoresis Reports of feeling bad Nausea Blood pressure at baseline level or slightly lower Tachycardia Pupillary dilation Yawning Hyperpnea Cold hands & feet Hypotension Bradycardia Visual disturbances Dizziness Loss of consciousness
San Francisco Syncope rule ‘C H E S S’ • Congestive heart failure history • Hematocrit < 30% • ECG (abnormal) • Shortness of breath • Systolic BP <90mmhg Higher risk for such patients Adverse outcomes include death, MI, arrhythmia, pulmonary embolism, stroke, subarachnoid haemorrhage
Management Four stages of syncope management; • Presyncope • Syncope • Delayed recovery • Post syncope
‘Presyncope’ STEP 1 Supine position Moving legs vigorously STEP 2 Circulation -> Airway -> Breathing Assessed as being adequate STEP 3 (Definitive care) O2 administered using full face mask Spirit of ammonia
‘SYNCOPE’ Step 1: POSITION • Terminate the dental procedure • Supine position with legs slightly elevated • Muscle movements helps increase the return of blood from the periphery ‘Trendelenburg position’
Step 2: C-A-B (circulation-airway-breathing) To assess circulation, ‘Carotid pulse’ is palpated In syncope, • Weak, thready carotid pulse • Slow heart rate To assess airway, • Adequate airway present when the patient’s chest moves and exhaled air can be heard & felt To assess breathing, • Spontaneous respiration is usually evident • Rescue breathing may be necessary ‘HEAD TILT-CHIN LIFT’ METHOD Positioning of the victim + Airway patency -> Rapid return of consciousness ‘LOOK, LISTEN, FEEL’
StepStep 3: Definitive care • Administration of O2 • Monitoring of vital signs (BP, heart rate, respiratory rate) • Additional procedures
• Loosening of binding clothes • Use of a respiratory stimulant, ‘AROMATIC AMMONIA’ • Cold towel placed on the forehead of a patient who is warm & blankets for those who feels cold • If bradycardia, anticholinergic such as Atropine i.v or i.m • Stimulus that precipitated the episode (syringe, an instrument or a piece of bloody gauze) • Frequently, hypoglycemia is involved - Administration of ‘sugar’ in form of orange juice or non diet soft drink
‘Delayed recovery’ • If the patient does not recover in 15-20 mins call for emergency medical services (EMS) • Perform Basic life support (BLS) • CAUSES - Seizure - Cerebrovascular accident (stroke) - Transient ischemic attacks (TIA) - Cardiac dysrhythmias - Hypoglycaemia
‘Post syncope’ • Not any additional dental treatment • Body may take 24 hr to settle down • Should determine the precipitating factors • Arrangements for adult escort to take patient home
References • Little and Falace’s Dental management of the medically compromised patient - 9th edition • SM Balaji’s Textbook of oral & maxillofacial surgery - 3rd edition • Stanley F Malamed’s Medical emergencies in the dental office • Harrison’s manual of medicine - 19th edition
Thankyou