What is Situational Syncope?
The Cleveland Clinic defines:
Situational syncope happens only during certain situations that affect your nervous system and lead to syncope. Some of these situations are:
- Intense emotional stress
- Use of alcohol or drugs
- Hyperventilation (breathing in too much oxygen and getting rid of too much carbon dioxide too quickly)
- Coughing forcefully, turning your neck or wearing a tight collar (carotid sinus hypersensitivity)
- Urinating (micturition syncope)
By now we have all been practicing long enough to know that being in the dental chair is not everyone’s cup of tea!
Some patients would much rather be out surfing or fishing than sit with their mouths open at the dentist. But unlike cars that can get dropped off for annual service, patients are not able to drop their jaws off to us and come back after to pick it up once treatment is completed!
The most common emergency we face in the dental surgery room would be that of situational syncope or commonly known as fainting.
This is where perhaps the patient didn’t sleep well the night before as he was worried and felt tense about his 8am Root Canal Therapy appointment. He felt too nauseous to have breakfast before the appointment. The very thought of having a needle jabbed into his gums made him rather anxious.
And while you were delivering your infamous painless technique of local anesthesia and thinking all was under control as the patient didn’t even flinch. Part way through your painless technique, the patient starts to squirm, first his legs, then his arms and fingers, then with his face movements he tries to tell you to stop that injection part way through as he wants to sit up.
His heart rate slows down but you don’t know that yet.. and the blood vessels in his legs start to expand. This then causes blood to pool in his legs, leading to a drop in blood pressure. He starts to feel hot and looks pale in the lips. He wants to sit up and catch his breath. But then the sudden movement from supine to 90 degrees causes his brain to not receive enough oxygen and he passes out.
You immediately position the chair to supine, making sure his head is lower than his legs. Your nurse quickly gives you the instant ice pack to crush and activate as you place it on your passed out patient’s forehead.
The patient’s mother is in the room too and she helps by raising both his legs high while the nurse runs out to get the pulse oximeter to monitor his oxygen saturation stats.
You silently focus, as in your mind you are thinking, if this is an allergy, I need my 1:1000 IM adrenaline. If the patient becomes unconscious I need to get on with DRS ABCD. You try to stay calm and do what is needed.
You can see his chest is rising and the stats are 97%. You can see the color is returning to his face and his lips are no longer pale and he starts to mumble to his mum about how he hates coming to the dentist!
So that is a real life example of situational syncope of the fearful and anxious patient who was needle phobic. Despite the anaesthetic being painless he had worked up his mind in such a state that his physiology followed to succumb.
And what about the state of mind of the dentist? When he knows he has that dreaded calcified root canal to deal with at 8am the next day on a fearful patient who is unable to open her mouth wide enough or long enough.
The dentist didn’t have a restful sleep either. He felt too worked up to have breakfast or drink any water in the morning. He starts the Root Canal Therapy but struggles to negotiate the calcified canal. He feels panic and needs to go to the bathroom twice in the middle of the procedure. He can hear his own heart palpitations and wonders if the patient can hear them too. He has a stern internal dialogue trying to figure out what else he can do to get to the apex of that curved canal.
In the meanwhile the patient is becoming more and more distressed and restless and the dentist now feels a heatwave coming on too. He asks his nurse to turn the AC to max as he silently hyperventilates behind his mask.