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Medical Emergencies in the Dental Setting

Medical Emergencies
by

Amisha Hindocha

on 20 March 2014

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Transcript of Medical Emergencies in the Dental Setting

Medical Emergencies
in the Dental Setting

Asthma
Patients with asthma (both adults and children) may have an attack while at the dental surgery. Most attacks will respond to a few ‘activations’ of the patient’s own short-acting beta2-adrenoceptor stimulant inhaler such as salbutamol
(100 micrograms/actuation).
Repeat doses may be necessary
Affected Structures
Anaphylaxis
Myocardial infarction
Syncope
Hypoglycemia
Seizure
Cause of Condition
Signs and Symptoms
Treatment
Reducing likelihood
Signs and Symptoms
Signs and symptoms may include: Urticaria, erythema, rhinitis, conjunctivitis.
Abdominal pain, vomiting, diarrhoea and a sense of impending doom.
Flushing is common, but pallor may also occur.
Marked upper airway (laryngeal) oedema and bronchospasm may develop, causing stridor, wheezing and/or a hoarse voice.
Vasodilation causes relative hypovolaemia leading to low blood pressure and collapse. This can cause cardiac arrest.
Respiratory arrest leading to cardiac arrest.
Treatment:
Up to date and accurate Med Hx
Check for known allergies including previous reaction to LA, Abx and Latex
Avoid possible allergens if suitable alternatives e.g latex free gloves
Referral for specialist assessment reccommended if unable to handle in primary care setting.
Dental team must be aware that no previous hx of allergen exposure is necessary for a serious reaction to occur
Anaphylactic reactions may also be associated with additives and excipients in medicines. It is wise therefore to check the full formulation of preparations which may contain allergenic fats or oils (including those for topical application, particularly if they are intended for use in the mouth).
First-line treatment includes
managing the airway and breathing and restoration of blood pressure
(laying the patient flat, raising the feet) and the administration of
oxygen (15 litres per minute).

For severe reactions where there are life-threatening airway and/or breathing and/or circulation problems, i.e., hoarseness, stridor, severe wheeze, cyanosis, pale, clammy, drowsy, confusion or coma reaction – Initial treatment of:

-Adrenaline
should be given
intramuscularly
(anterolateral aspect of the middle third of the thigh) in a dose of
500 micrograms (0.5 mL adrenaline injection of 1:1000)
-an autoinjector preparation delivering a dose of
300 micrograms (0.3 mL adrenaline injection 1:1000)
is available for
immediate self-administration by those patients known to have severe reactions.
This is an acceptable alternative if immediately available. The dose is
repeated if necessary at 5 minute intervals
according to blood pressure, pulse and respiratory function.

Paediatric dose for adrenaline is based on the child’s approximate age or weight.

In any unconscious patient always check for ‘signs of life’ (breathing and circulation) and start CPR in the absence of signs of life or normal breathing

In less severe cases any wheeze or difficulty breathing can be treated with a salbutamol inhaler

All patients treated for an anaphylactic reaction should be sent to hospital by ambulance for further assessment, irrespective of any initial recovery.

Antihistamine drugs and steroids, whilst useful in the treatment of anaphylaxis, are not first line drugs and they will be administered by the ambulance personnel if necessary.
With an up to date and accurate Med hx, we can determine how likely or not an attack is.
Can flare due to:
allergens
irritants
exercise
stress
cold
Whilst awaiting ambulance transfer, oxygen (15 litres per minute) should be given
Assuming the patient’s nebuliser is unavailable, up to 10 activations from the salbutamol inhaler should be given using a large-volume spacer device and repeated every 10 minutes if necessary until an ambulance arrives.
If asthma is part of a more generalised anaphylactic reaction or if signs of life threatening asthma are present, an intramuscular injection of adrenaline should be given.
If any patient becomes unresponsive always check for ‘signs of life’ (breathing and circulation) and start CPR in the absence of signs of life or normal breathing
Myocardial infarction
Progressive onset of severe, crushing pain in the centre and across the front of chest. The pain may radiate to the shoulders and down the arms (more commonly the left), into the neck and jaw or through to the back.


Signs and Symptoms
Causes:

Anaphylaxis is a severe, life-threatening, generalised or systemic hypersensitivity reaction. It is characterised by rapidly developing life-threatening airway and/or breathing and/or circulation problems usually associated with skin and mucosal changes.

Anaphylactic reactions in general dental practice may follow the administration of a drug or contact with substances such as latex in surgical gloves. In general, the more rapid the onset of the reaction, the more serious it will be. Symptoms can develop within minutes and early, effective treatment may be life saving.





Skin becomes pale and clammy.
Nausea and vomiting are common.
Pulse may be weak and blood pressure may fall.
Shortness of breath.
Treatment
Call
999
immediately for a cardiac ambulance.
Allow the patient to rest in the position that feels most comfortable
Give
sublingual GTN spray
Reassure
the patient to relieve further anxiety.
Give aspirin- 300 mg orally
, crushed or chewed.
High flow oxygen
may be administered (15 litres per minute) if the patient is cyanosed (blue lips) or conscious level deteriorates.
If the patient becomes
unresponsive
always check for ‘signs of life’ (breathing and circulation) and
start CPR
in the absence of signs of life

Patients with epilepsy must continue their normal dosage of anticonvulsant drugs before attending for dental treatment. Epileptic patients may not volunteer the information that they are epileptic, but there should be little difficulty in recognising a tonic-clonic (grand mal) seizure.
Being aware
Medication
Treatment
Signs and symptoms
Treatment:
Signs and symptoms:
Treatment
Treatment
Signs & Symptoms:
Early treatment
Signs & Symptoms
Dental patients are susceptible to choking with the potential risk of aspiration. They may have blood and secretions in their mouths for prolonged periods. Local anaesthesia may diminish the normal protective pharyngeal reflexes and ‘impression material’ or dental equipment is often within their oral cavity and poses additional risks. Good teamwork and careful attention to detail should prevent aspiration episodes and any risk of choking.
Stress
Dehydration
Diabetes
Medication
Hypotension (in elderly)
External triggers-unpleasant sights, pain or heat
Patient feels faint / dizzy / light headed.
Slow pulse rate.
Low blood pressure.
Pallor and sweating.
Nausea and vomiting.
Loss of consciousness.
Make sure the area is safe
Lay the patient flat as soon as possible and raise the legs to improve venous return.
Loosen any tight clothing, especially around the neck and give oxygen (15 litres per minute).
If patient becomes unresponsive, check for ‘signs of life’ and start CPR


Where the patient is co-operative and conscious with an intact gag reflex, give oral glucose. If necessary this may be repeated in 10 -15 minutes.
Shaking and trembling
Sweating
Headache
Difficulty in concentration / vagueness
Slurring of speech
Aggression and confusion
Fitting / seizures
Unconsciousness
With prolonged or recurrent seizures, ambulance personnel will often administer IV diazepam which is usually rapidly effective in stopping any seizure.

An alternative, although less effective treatment in the dental setting, is midazolam given via the buccal route in a single dose of 10mg for adults.

For children the dose can be simplified as follows:
Child 1-5 years 5mg,
Child 5-10 years 7.5mg,
Above 10 years 10mg

This might usefully be administered while waiting for ambulance treatment, but the decision to do this will depend on individual circumstances
There may be a brief warning or ‘aura’.
Sudden loss of consciousness, the patient becomes rigid, falls, may give cry, and becomes cyanosed (tonic phase).
After a few seconds, there are jerking movements of the limbs; the tongue may be bitten (clonic phase).
There may be frothing from the mouth and urinary incontinence.
The seizure typically lasts a few minutes; the patient may then become floppy but remain unconscious.
After a variable time the patient regains consciousness but may remain confused.
Fitting may be a presenting sign of Hypoglycaemia and should be considered in all patients, especially known diabetics and children. An early blood glucose measurement is essential in all actively fitting patients (including known epileptics).
Check for the presence of a very slow heart rate (<40 per minute) which may drop the blood pressure. This is usually caused by a vasovagal episode (see Syncope section below). The drop in blood pressure may cause transient cerebral hypoxia and give rise to a brief seizure
The patient may cough and splutter.
They may complain of difficulty breathing.
Breathing may become noisy with wheeze (usually aspiration) or stridor (usually upper airway obstruction).
They may develop ‘paradoxical’ chest or abdominal movements.
They may become cyanosed and lose consciousness
The treatment of the choking patient involves removing any visible foreign bodies from the mouth and pharynx.
In case of aspiration, cough vigorously
Symptomatic treatment of wheeze with a salbutamol inhaler may help (as for asthma)
If large pieces of foreign material material have been aspirated, e.g. teeth or dental amalgam, the patient should be referred to hospital for a chest x-ray if possible
Where the patient is symptomatic following aspiration they should be referred to hospital as an emergency.
STAFF TRAINING
CPD
- 10 hours in every CPD cycle
-Recommendation of at least two hours of CPD every year
Responsibility for checking resuscitation equipment rests with the individual dental practice where the equipment is held. This process should be designated to named individuals. The frequency should ideally be weekly.

Medical Emergency Kit
Recommended Emergency Equipment

-Portable Oxygen cylinder (D size) with pressure reduction valve and flowmeter
-Oxygen face mask with tubing
-Basic set of oropharyngeal airways (size 1,2,3,4)
-Pocket mask with Oxygen port
-Self inflating bag and mask apparatus with oxygen reservoir and tubing
-Variety of well fitting adult and child face masks for attaching to self inflating bag
-Portable suction with appropriate suction catheters and tubing
-Single use syringes and needles
-Spacer; device for inhaler bronchodilators
-Automated blood glucose measurement device
-Automated External Defibrillator
Recommended Emergency Drugs

-Glyceryl Trinitrite Spray (GTN)- 400 micrograms/dose
-Salbutamol aerosol inhaler-100 micrograms/actuation
-Adrenaline injection- 1/1000, 1mg/m
-Glucagon injection 1mg
-Oral glucose solution/tablets/gel/powder
-Midazolam 5mg/ml or 10mg/ml (buccal or intranasal)
-Oxygen

AUDITS
A system must be in place for identifying which equipment requires special training, such as defibrillators (AEDs) and self-inflating bag and mask devices.
All general dental practices should recognize the need for and make provision for staff to have sufficient time to train in resuscitation skills as part of their employment
To ensure a
high quality service,
general dental practices should
audit:
-
Weekly checks
of the emergency medical equipment and drugs.
-
All medical emergencies
that occur
on site
including near miss events.
-Ideally, audit should i
nclude periods of ‘debriefing
’ after any medical emergency. This allows staff to reflect on the treatment given and permits discussion of whether anything might have been done differently.
Regular staff meetings
will often provide the ideal forum for such discussions.
-Where audit has identified
deficiencies,
steps must be taken to
improve performance.

Apple Dental Practice and New Chestnuts Dental Practice
VT Training Year
-Med hx forms -written and on the computer
-Practice protocol for updating med hx is- on every examination and each appt check for changes.Audits carried out on record keeping- one domain is med hx updating. Financial penalties for poor record keeping.
-Staff training annually- Next one n Jan 2014, verifiable and certificated.
-Practice meetings
-Medical emergency cupboard
-Crib sheets and allocated roles


A planned replacement programme should be in place for equipment and drugs that are used or reach their expiry date.
Clinical features of acute- severe asthma in adults include:
- Inability to complete sentences in one breath.
- Respiratory rate > 25 per minute.
- Tachycardia (heart rate > 110 per minute

Clinical features of life threatening asthma in adults include:
- Cyanosis or respiratory rate < 8 per minute.
- Bradycardia (heart rate < 50 per minute).
- Exhaustion, confusion, decreased conscious level.
References and Guidelines
Later treatment
The patient has impaired consciousness, is uncooperative, IM Glucagon should be given.
It may take 5-10 minutes to work
Re-check blood glucose after 10 minutes to ensure that it has risen to a level of 5.0 mmol/per litre in conjunction with an improvement in the patient’s mental status.
If patient becomes unconscious, start CPR

GDC REGULATIONS
Patients with diabetes should eat normally and take their usual dose of insulin or oral hypoglycaemic agent before any planned dental treatment.
If food is omitted after having insulin, the blood glucose will fall to a low level (hypoglycaemia)-blood glucose <3.0mmol/perlitre
Patients may recognize the symptoms themselves and will usually respond quickly to glucose.
Children may not have such obvious features but may appear lethargic.
Inadequate cerebral perfusion (and oxygenation) results in loss of consciousness. This most commonly occurs with low blood pressure caused by vagal overactivity (a vasovagal attack, simple faint, or syncope). This in turn may follow emotional stress or pain. Some patients are more prone to this and have a history of repeated faints.
Choking and Aspiration
Encourage the patient to cough if conscious. If they are unable to cough but remain conscious then sharp back blows should be delivered. These can be followed by abdominal thrusts if the foreign body has not been dislodged.
If the patient becomes unconscious, CPR should be started
During a seizure try to ensure that the patient is not at risk from injury but make no attempt to put anything in the mouth or between the teeth.
Do not attempt to insert an oropharyngeal airway or other airway adjunct while the patient is actively fitting.
Give high flow oxygen (15 litres per minute).
Do not attempt to restrain convulsive movements.
After convulsive movements have subsided place the patient in the recovery position and reassess.
If the patient remains unresponsive always check for ‘signs of life’ and start CPR.
Check Blood glucose to exclude hypoglycaemia, If <3.0 mmol per litre or hypoglycaemia is clinically suspected, give oral/buccal glucose, or glucagon.
Attended Medical Emergency Study day with CPR training
Attended the 'Four handed dentistry' course- expressed importance of the value of the dental nurse in all aspects
Attendance at Endondontics/Rubber Dam Course- expressed importance in relation to patient safety
Attendance at Centre Parcs conference- GDC Fitness to practice
Developing practice protocol with crib sheets and specific roles for members of staff to improve effectiveness of handling a medical emergency
Dealing with medical emergencies within my surgery
Attendance at practice CPR training day in Jan 2014
The General Dental Council (GDC)
GDC document 2002 ‘The First Five Years, A Framework for Undergraduate Dental Education'
The Resuscitation Council UK
Thank You.
CPR and Recovery Position
Medical Emergency Test
1) The most frequent medical emergency in the dental office is ____________________.

myocardial infarction
syncope
respiratory arrest
allergic reactions

2) The ______________ artery is used when taking a patient’s blood pressure.

brachial
carotid
radial
femoral

3)The best position in which to place a syncopal patient is _______________________.

seated with the patient’s head between their legs
supine with the legs elevated
on their side
in a seated position

4)Most emergencies occur ______________________.

in the reception room
after treatment is completed
while under nitrous oxide sedation
during or immediately following local anesthesia administration

5)Mrs. Smith, a 57-year-old diabetic, is having extensive bridgework completed during her lunch break appointment. She begins acting strangely, her pulse is rapid, and her skin is pale, cool, and clammy. You suspect _________________ and treat it with _________________.

asthma; puff from her inhaler
hypoglycemia; oral sugar
angina; nitroglycerin
stroke; oxygen
Full transcript