Back to basics: emergency medicine in dentistry

It is important that all members of the dental office staff be trained to promptly recognize and efficiently manage emergency situations. This paper discusses how to prepare a dental office and staff for emergencies. It also describes several emergencies that may occur in dental offices and discusses methods of handling them.     

Two-stage urethra-plasty

This article reviews special considerations for children with psychiatric conditions when they present with pediatric emergencies. The review spans a variety of scientific disciplines and attempts to integrate information that is not usually available to the emergency practitioner from a single source; the intent is not to be exhaustive on any particular topic but to organize what is most relevant to pediatric emergency care. Topics that are discussed include: 1) a brief review of true psychiatric emergencies, 2) side effects of psychotropic medications that have direct implications for emergency assessment and management, 3) neurologic disorders that present with psychiatric manifestations, and 4) psychiatric disorders that present with somatic manifestations.     

Emergencies: What are they and do they influence bystanders to intervene?

Empirical literature does not seem to be available on what factors bystanders use to define an emergency nor the effect of such a decision on the rate of helping. A series of 4 studies, employing 1,232 undergraduates, sought to answer these questions. Results show the following: (a) Emergencies are a subclass of problem situation that usually result from accidents. (b) There is a high degree of agreement concerning what problem situations are definitely emergencies. (c) Emergency situations are differentiated from other problem situations by threat of harm or actual harm worsening with time, unavailability of an easy solution to the problem, and necessity of obtaining outside help to solve the problem. (d) Disagreement on whether a problem situation is an emergency or not results from differing perceptions of the degree to which threat of harm or actual harm worsens with time. (e) Bystanders are more likely to help in emergency than in nonemergency problem situations. Results indicate that the need of the victim is a salient feature used by bystanders in determining whether or not to help. (21 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Emergency stiuations connected with electrolyte disorders. Special aspects

Electrolyte-induced situations which are dangerous to life usually result from disturbances of the extracellular volume (ECV), osmolarity, the potassium level or the acid-base equilibrium. In recent years (thanks to the wide spread use of hormone therapy for mammary carcinoma) severe hypercalcemia has increased in importance as a life-threatening complication, while hypocalcemia, at least in adults, should only very seldom lead to unexpected emergencies. As long as serious clinical symptoms do not suggest an emergency, assessment of the threat to the patient as a result of the existing electrolyte disturbance often causes some difficulty. Besides the extent of the deviation from normal, the rate of development of the disturbance determines the resulting danger: chronic hypo-osmolarity, and especially hyperosmolarity are occasionally tolerated without symptoms while acute disturbances of the same or a less extent lead to severe central nervous symptoms. A similar state of affairs is also true of the emergency situations arising from disturbances of the acid-base equilibrium, among which the respiratory disorders are particularly important clinically. In the case of threatening disorders of the potassium metabolism, the accompanying circumstances (digitalis, simultaneous disorders and treatment of the acid-base equilibrium) often determine the clinical significance and danger to the patient. Clinical symptoms, anticipation ("expecting the unexpected"), prevention and treatment of emergency situations of fluid volume, osmolarity, potassium and acid-base equilibrium are the subjects of this paper.     

Management of eye emergencies in the accident and emergency department by senior house officers: a national survey

OBJECTIVE: To assess the training that accident and emergency (A&E) senior house officers (SHOs) receive in dealing with eye emergencies, their own perceived level of confidence and competence in managing such cases, and the availability of appropriate equipment in their departments. METHODS: Prospective telephone survey using a standardised structured questionnaire. One SHO from each United Kingdom A&E department listed in the BAEM directory of 1993 was chosen at random and interviewed. RESULTS: 226 A&E departments were contacted and 192 SHOs were successfully interviewed (response rate 84.9%); 26.0% received no training in the management of eye emergencies, 68.8% had only a little or no confidence in dealing with these cases, and 42.2% worked in A&E departments which had no slit lamp. CONCLUSIONS: There is a lack of adequate basic ophthalmic training for A&E SHOs, leading to a lack of confidence on their part in the management of eye emergencies. In just over 40% of A&E departments in the United Kingdom, the management of these cases may be less than optimal because of the absence of a slit lamp.     

Hematologic emergencies

The most common life-threatening hematologic emergencies include hemorrhage and severe anemia. Successful treatment of these conditions depends on the emergency veterinarian having a thorough understanding of the possible etiologies of these conditions, and a systematic approach to diagnosis and therapy. Use of blood component therapy can be a life-saving technique in these patients. The goal of this article is to familiarize the emergency veterinarian with a systematic approach to the diagnosis and treatment of hematologic emergencies.     

A road map from Nebraska

OBJECTIVE: To describe the arrangements for the provision of emergency dental services for students at the University of Manchester and to report data collected during the first four and a half years of the student emergency dental services (SEDS) unit based at the University Dental Hospital of Manchester. METHOD: Data pertaining to every student attending SEDS since its inception were collected by means of questionnaire including provision to record diagnoses, treatment needs and the emergency care provided. RESULTS: The incidence of dental emergencies within the student population served by SEDS has been found to be 39 emergencies per 1000 students per annum, with the service being most heavily used by overseas students. Caries, pulpal pathology and failed restorations account for 46 per cent of the presenting emergencies, with pericoronitis (19 per cent) and other emergencies of periodontal origin (14 per cent) being common place. CONCLUSION: It is concluded that a student emergency dental service may be found to be an important element of student medical and related welfare services.     

A sudden awakening from a near coma after combined intake of gamma-hydroxybutyric acid (GHB) and ethanol

OBJECTIVE: The excess of pediatric emergencies going to hospitals has been the subject of many studies in Spain and, on some occasions, this problem has attributed to the inefficiency of pediatric primary care. Our main objective was to evaluate whether or not our community health center is an efficient filter for hospital emergencies. PATIENTS AND METHODS: We conducted a prospective one year long study of all pediatric emergency demands within our normal office hours (workdays, from 08:00 to 21:00 hours). RESULTS: The total number of emergencies amounted to 1,294, with an average of 5.78 per day. The largest inflow occurred in September and the lowest in August. Most of the emergencies were between 16:00 and 19:00 hours. Fifty percent of the patients were under 4 years of age. We made 86 different diagnoses according to the WONCA classification. Only 10 diagnoses came with a frequency superior to 3%, and 60% of the emergencies were related to one of these 10 diagnoses. Of all pediatric emergencies, 94.7% were completely resolved by us. Only 60 patients (4.6%) were sent-on to hospital emergency services. Among these patients, 40 required traumatological or surgical attention, 5 ophthalmological care, 3 otorhinolaryngological care, and only 12 exclusively needed pediatric attention. In 55.7% of the cases there was no reason to use the emergency channel. CONCLUSIONS: During our office hours, our community health center is an efficient filter for hospital pediatric emergencies.     

Bystander anonymity and reactions to emergencies.

Two experiments with 179 undergraduates investigated the impact of anonymity on bystander reactions to emergencies and on the timing of bystander decision making. The experiments differed in the nature of the emergency (violent assault vs seizure) and in the speed with which the emergency developed from relative ambiguity to unequivocal clarity concerning the victim's need for help. In both experiments, an additional bystander's awareness of the emergency and the S's anonymity were crossed in a 2?×?2 factorial design. Anonymity vis-à-vis the victim had no effects on helping. Anonymity vis-à-vis the other bystander did affect helping, apparently by reducing evaluation apprehension. Whether evaluation apprehension enhances or inhibits helping depends on the expectations attributed to other bystanders. The timing of effects suggests that when emergencies are ambiguous, anonymity (through reduced involvement) delays making the decision regarding whether help is appropriate. Once emergencies are clear, anonymity (through evaluation apprehension) influences the decision regarding one's own obligation to intervene. (15 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Clonidine reduces dopamine and increases GABA in the nucleus accumbens: an in vivo microdialysis study

The spectrum of infectious disease (ID) emergencies in hospitalized patients was assessed in a prospective study of 3,626 inpatient ID consultations in a 1,350-bed teaching hospital. ID emergencies, defined by a need or anticipated need for advanced life support or by irreversible organ damage leading to permanent functional loss, were encountered in 175 patients. Infections of the central nervous system (26.3%), cardiovascular system (14.9%), alimentary system (13.1%), and lower respiratory tract (7.4%) and adverse reactions to antimicrobial agents (7.4%) were most common. In 18.9% of the cases, the referring clinicians were unaware of the emergency at the time of referral. Drug reactions (46.1%), severe alimentary and peritoneal infections (32.0%), upper respiratory tract infections (28.6%), and skin and soft-tissue infections (27.3%) were most frequently missed. The emergency ID conditions were not recognized because they had an atypical presentation (51.5%), were not commonly seen in the referring specialty (24.2%), were due to rare organisms (15.2%), or had unusual anatomical sites of involvement (9.1%). A close liaison between clinicians and the ID team is crucial for recognition of ID emergencies at their early stages so that appropriate investigations and management can be instituted expediently, before the occurrence of irreversible damage.     

Difficulties in delivery, including shoulder dystocia and malpresentations of the fetus

Shoulder dystocia is a true obsteric emergency. It may be suspected in large multiparous women, women who have previously delivered large babies, prolonged pregnancy, women who make poor progress in labor, and when the fetus seems very large to palpation. Women with abnormal pelves should be suspect. More liberal use of cesarean section in these situations will reduce the incidence of shoulder dystocia. It is important to have a carefully considered plan of action if shoulder dystocia does occur. The most helpful and definitive maneuver is extration of the posterior arm. Malpresentations cause acute emergencies mainly because of the associated increased incidence of prolapse of the cord. This possibility should be evaluated immediately when rupture of the membranes occurs. Prompt delivery by cesarean section is the treatment of choice with this complications.     

Racing to help: Racial bias in high emergency helping situations.

The present work explored the influence of emergency severity on racial bias in helping behavior. Three studies placed participants in staged emergencies and measured differences in the speed and quantity of help offered to Black and White victims. Consistent with predictions, as the level of emergency increased, the speed and quality of help White participants offered to Black victims relative to White victims decreased. In line with the authors' predictions based on an integration of aversive racism theory and the arousal: cost-reward perspective on prosocial behavior, severe emergencies with Black victims elicited high levels of aversion from White helpers, and these high levels of aversion were directly related to the slower help offered to Black victims but not to White victims (Study 1). In addition, the bias was related to White individuals' interpretation of the emergency as less severe and themselves as less responsible to help Black victims rather than White victims (Studies 2 and 3). Study 3 also illustrated that emergency racial bias is unique to White individuals' responses to Black victims and not evinced by Black helpers. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Surgical management of portal hypertension

The surgical management of portal hypertension depends on the location of the obstruction. Suprahepatic obstruction is usually optimally treated by a surgical portacaval shunt. In extrahepatic obstruction the treatment should be sclerotherapy. For intrahepatic obstruction in emergency situations, sclerotherapy is the first choice, with portacaval systemic shunts or transjugular intrahepatic portal systemic stent shunt the second option. Liver transplantation in other situations should, if possible, be considered ahead of a portal diversion.     

Diving-related emergencies

The proliferation of sport or recreational divers over the last several decades has resulted in significant increases in the number of patients treated for diving-related emergencies. The treatment of these individuals is no longer confined to a small group of physicians with special training or experience. Rather, community emergency physicians and physicians engaged in the practice of travel medicine are increasingly called on to treat such patients. This article discusses general physical principles relating to diving medicine and common presentations and treatment of diving-related emergencies.     

Drugs in the physician's bag for emergency conditions

The list of drugs for the physician's bag depends on several factors, including practice location, conditions most likely to be found, costs and availability of drugs, organization of the emergency medicine in the region, shelf life and climatic vulnerability of certain drugs, population age, and size and design of the bag. Most of the drugs carried should be in an injectable form. However, the non-injectable drugs with relatively rapid systemic onset may be also included. Separation of drugs in the bag according to their usage may help in providing an organized treatment. For example, one could separate drugs for treatment of the following emergencies: cardiovascular, altered mental status, respiratory, gastrointestinal, bleeding, infections, and toxicological emergencies. The list of drugs needed for medical emergencies when physician makes house-calls is presented with short notes on their usage. Oncologic, toxicologic and pediatric emergencies are commented.     

Diagnosing psychiatric emergencies in the elderly

Psychiatric emergencies in the elderly form a small percent of all elderly patients treated in emergency departments. However, accurately diagnosing and understanding behavioral emergencies in the elderly is difficult. Emergency behavioral syndromes in the elderly include confusion, agitation, psychosis, and behavioral regression. Causes of these syndromes in the elderly include delirium, dementia, medication side effects, physical illnesses, depression, and alcohol intoxication/dependency. Emergency physicians should consider each of these diagnostic possibilities when evaluating elderly behavioral emergencies to properly diagnose and treat elderly patients.     

Determination of sinefungin in rat plasma by high-performance liquid chromatography

This is the 31st article in a continuing series of objectives to direct emergency medicine resident experiences on off-service rotations. Neck and torso trauma accounts for a large portion of injuries, and its management is an essential part of training in emergency medicine. Due to the often life-threatening presentations of trauma victims, resident instruction may be conducted at the bedside in difficult and demanding situations. Therefore, it is essential for residents to have specific goals and objectives to guide their acquisition of knowledge required to make critical decisions for patients with major trauma.     

Managing medical emergencies

A simple dental procedure can quickly escalate into a medical emergency. Management of six common emergencies is described.     

Colorectal cancer emergencies

From the variety of operative choices for colorectal cancer emergencies, it is difficult to select the best one for the individual patient, who is often old and frail. Appropriate handling of the emergency situation is essential. Treatment of the patient's malignant disease is secondary. The choice of surgical procedure in colorectal cancer emergencies must be based on sound clinical judgement and should be in keeping with the technical skill and experience of the individual surgeon. Surgical failures have major negative consequences not only for the immediate postoperative course, but also for long-term survival and quality of life of these patients.     

First-aid management of psychological emergencies: 1

Psychological emergencies are complex events whose management requires considerable skill on the part of the nurse aider. This article, the first in a series on the management of psychological emergencies, outlines the main areas of assessment and the nurse-aid management of a psychologically disturbed person.