medical problems and emergency

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Medical Problem & EmergencyMedical Problem & Emergency

in Dentistryin Dentistry



IntroductionIntroduction

y There is a public expectation that Dental Practitionersand Dental Care Professionals should be competent inmanaging common medical emergencies. As such, wemay have to deal with medical emergencies.

y Fortunately, these arerare.

y The commonest problems, namely, vasovagal syncope(faints), hypoglycaemia, angina, seizures, choking, asthmaand anaphylaxis have been reported to occur at ratesbetween 0.7 cases per dentist per year (Girdler, 1999)or on average once every 3 to 4 years.



Preparation for emergenciesPreparation for emergencies1) Prevention

- medical history

2) Training

- Staffs



3) Equipment

- Oxygen cylinder (D size) with pressure reduction valveand flow meter. to be easily portable but also allow for

adequate flow rates, e.g., 10-15 litres per minute.

- Oxygen face mask with tubing

- Syringe and needle

- Bag mask device with O2 reservoir- Basic airway adjuncts

- High suction, large diameter & round ended

- BP recording device

- Blood glucose measurement device.

- Automatic external defibrillator (AED)- Spacer device to deliver salbutamol

- Paper bag



y Cylinder with flow meter with humidifier

y High flow mask 10-15 L/min =100%

y Face mask-8-10 L/min=40-60%

y Nasal prong 1L = 24-25%

2L = 27-29%

3L = 30-33%

4L = 33-37%



4) Drugs

- Oxygen- Adrenaline (1:1000, 1mg/ml)

- Glyceryl trinitrate (GTN) spray (400micrograms/dose)

or tablet

- Aspirin tablet (300mg)- Salbutamol aerosol inhaler

(100micrograms/actuation)

- Prednisolone tablet

- Glucagon injection 1mg- Oral glucose solution / tablets / gel / powder



Management of medicalManagement of medical

emergencies patientemergencies patient

y A systematic approach to recognizing the

acutely ill patient based on the ¶ABCDE·principles is recommended.



General principles

1. Follow the Airway, Breathing, Circulation, Disability, and

Exposure approach (ABCDE) to assess and treat the patient.2. Treat life-threatening problems as they are identified before

moving to the next part of the assessment.

3. Continually re-assess starting with Airway if there is further

deterioration and effects of treatment given.

4. Recognize when you need extra help and call for help early.5. Organise your team and communicate effectively.

6. The aims of initial treatment are to keep the patient alive, achieve

some clinical improvement and buy time for further treatment

whilst waiting for help.

7. The ABCDE approach can be used irrespective of your training and

in or treatment. Individual experience and training will determine

which treatments you can give. Often only simple measures such as

laying the patient down or giving oxygen are needed.



First stepFirst step

y Stay calm. Ensure that you and your staff are safe.

y Look at the patient generally to see if they ¶look unwell·.

y In an awake patient ask, ´How are you?µ If the patient

is unresponsive,y shake him and ask, ´Are you all right?µ If they respond

normally, they have a clear airway, are breathing andhave brain perfusion. If they speak only in shortsentences, they may have breathing problems. Failure

of the patient to respond suggests that they areunwell. If they are not breathing and have no pulse orsigns of life, start CPR according to currentresuscitation guidelines.



AirwayAirway

y In most cases, only simple methods of airwayclearance are needed: Airway openingmanoeuvres ² head tilt/ chin lift or jaw thrust.

y Remove visible foreign bodies, debris or blood

from the airway (use suction or forceps asnecessary).

y Consider simple airway adjuncts e.g.,oropharyngeal airway.

y Give oxygen at a high inspired concentration:

y Use a mask with an oxygen reservoir. Ensure thatthe oxygen flow is sufficient (10-15 litres perminute) to prevent collapse of the reservoirduring inspiration.



BreathingBreathing

y Look, listen and feel for the general signs of respiratory distress: sweating, central cyanosis (bluelips and tongue), use of the accessory muscles of respiration (muscles of the neck) and abdominalbreathing.

y Count the respiratory rate. The normal adult rate is12-20 breath/min, children rate is 20-30breath/min.

y If any patient·s depth or rate of breathing isinadequate, or you cannot detect

y any breathing, use bag and mask (if trained) or pocketmask ventilation with

y supplemental oxygen while calling urgently for anambulance.



CirculationCirculation

y Assess the pulse. Count the patient·s pulse rate.

y Look at the colour of the hands and fingers: are

they blue, pink, pale?

y Assess the limb temperature by feeling thepatient·s hands: are they cool or

warm?



DisabilityDisabilityy

Common causes of unconsciousness include profound hypoxia,hypercapnia (raised carbon dioxide levels), cerebral hypoperfusion

(low blood pressure), or the recent administration of sedatives or

analgesic drugs.

y Review and treat the ABCs: exclude hypoxia and low blood

pressure.

y Check the patient·s drug record for reversible drug-induced causes

of depressed consciousness.

y Examine the pupils (size, equality and reaction to light).

y Make a rapid initial assessment of the patient·s conscious level using

the AVPU method: Alert, responds to Vocal stimuli, respondsto Painful stimuli or Unresponsive to all stimuli.

y Measure the blood glucose to exclude hypoglycaemia, using a

glucose meter. If below 3.0 mmol per litre give the patient a glucose

containing drink to raise the blood sugar or glucose by other

means (see Appendix (ii) Hypoglycaemia).



ExposureExposure

y To assess and treat the patient properly

loosening or removal of some of the

patient·s clothes may be necessary.

y Respect the patient·s dignity.

y This will allow you to see any rashes (e.g.,

anaphylaxis) or perform procedures (e.g.,

defibrillation).



UnconsciousnessUnconsciousness

y Can results from medical conditions, drug

administration, or trauma.

y E.g. cardiac arrest, motor vehicle accident.

y What to do?

- Initiate basic life support to resuscitate.

- To restore and maintain circulation and

oxygenation.

y How?



ManagementManagement

DRs ABC

y Danger- Ensure safety

y Responsiveness- If it is an adult, simple tap or shake and ask

´are you ok?µ; if it is a baby, speak loudly or pinch gently

y Send- an assistant for help

y Airway- Open the airway

y Breathing- Start rescue breathing if there is no breathing

y

Circulation- Chest compression if there is no pulse



Syncope (Syncope (VasovagalVasovagal syncope)syncope)

y Defined as transient loss of consciousness due

to cerebral ischaemia caused by a reduction in

blood supply to the brain.

y Vasodilation causes pooling of blood in theperipheries and vagal stimulation causes slowing

of the heart, results in dramatic fall in BP.

y Presentation: light headed, dizziness, agitated,

pale and sweaty, slow pulse and hypotension.




1) Lie the patient flat, raise patient·s legs.

2) Relieve any compression on the neck and maintain anairway.

3) Give supplemental oxygen (10-15litres per minute).

4) When consciousness is regained, patient should bekept flat and reassured.

5) Once pulse and BP recover, slowly raise patient toseated position.

6) If there is significant medical problems, or whensyncope is prolonged or complicated by seizure,transfer patient to hospital for further assessment.

7) If any patient becomes unresponsive, always check for¶signs of life· (breathing, circulation) and start CPR inthe absence of signs of life or normal breathing



AnaphylaxisAnaphylaxis

y Anaphylaxis is a severe, life-threatening,generalised or systemic hypersensitivity

reaction. It is characterised by rapidly developinglife-threatening airway and/or breathing

and/or circulation problems usually associatedwith skin and mucosal changes.

y Exaggerated immune response to foreign material

y Presentation: urticaria, angioedema, stridor,wheezing and/or a hoarse voice, flushing,hypotension, tarchycardia, bronchospasm

y Respiratory arrest leading to cardiac arrest.



ManagementManagement1) Stop administration of drugs

2) Use an ABCDE approach

3) Assess severity of cardiovascular collapse (pulse and BP)

4) Assess degree of airway obstruction (angioedema- upper, bronchospasm-

lower)5) Call for help

6) Patient supine, raise leg if low BP

7) Give O2 (10-15 litres per minute)

8) Monitor consciousness and vital signs

9) For shock, angioedema or bronchospasm :

- Give Adrenalin IM 1:1000 (0.5mg), repeat every 5

minutes while waiting for ambulance

10) All patients treated for an anaphylactic reaction should be sent to hospital

by ambulance for further assessment, irrespective of any initial recovery.



AsthmaAsthma

- 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.




1) Assess severity

a) Acute severe- unable to speak in

sentence, pulse rate> 110/min, respi

rate> 25/minb) Life threthening- silent chest, cynosis,

sweating, respi rate< 8/min,

bradycardia/hypertension, confusion,

agitation.If more than 1 feature severe, or any life

threathening, arrange transfer to hospital.



2) Otherwise:

- High flow O2(10-15 litres per minute)

- 4²6 activations from the salbutamol inhalershould be given using a large-volume spacer

device and repeated every 10 minutes if

necessary until an ambulance arrives.

- Prednisolone 30-60mg orally

- If asthma is part of a more generalised anaphylacticreaction or if signs of life threatening asthma are present,

give an intramuscular injection of adrenaline

- If not improving transfer to hospital.

- If any patient becomes unresponsive always check for ¶signs

of life· (breathing and circulation) and start CPR in theabsence of signs of life or normal breathing



HypoglycemiaHypoglycemia

y Occurs in patients on anti-diabetic medications.

y Symptoms: sweating, hunger, tremor, agitation,

drowsiness, confusion, coma.

y Assume any diabetic patient with impairedconsciousness had hypoglycemia until proven

otherwise.




y Confirm the diagnosis by measuring the blood glucose.

y If conscious, give oral carbohydrates. e.g fruit juice, glucose powder

neat or dissolved in water. After 10 minutes, followed up with fodd

contains longer acting carbohydrate.

y I

n more severe cases - where the patient has impairedconsciousness, is uncooperative or is unable to swallow safely

buccal glucose gel and / or glucagon should be given.

y Glucagon should be given via the IM route (1mg in adults and

children >8years old or >25 kg; 0.5mg if <8 years old or <25 kg).

y

Re-check blood glucose after 10 minutes to ensure that it has risento level of 5.0 mmol per litre or more, in conjunction with an

improvement in the patient·s mental status.

y If the patient is unconscious, check for ¶signs of life· (breathing and

circulation) and start CPR in the absence of signs of life or normal

breathing. Activate emergency medical support.



Symptoms and signs

y There may be a brief warning or ¶aura·.

y Sudden loss of consciousness, the patient becomes rigid, falls,

may give a cry, and becomes cyanosed (tonic phase).

y After a few seconds, there are jerking movements of the

limbs; the tongue may be bitten (clonic phase).

y There may be frothing from the mouth and urinary

incontinence.

y The seizure typically lasts a few minutes; the patient may then

become floppy but remain unconscious.

y After a variable time the patient regains consciousness but

may remain confused.

y It may be a presentation of hypoglycemia or vasovagal attack.

EpilepsyEpilepsy



1) Remove dangerous object from mouth and around patient.

2) Loosen tight clothing.

3) Do not restrain the patient.

4) The mouth should not be forced open, nor attempt made to insert any object into themouth

5) Give high flow oxygen (10-15 litres per minute).

6) Turn the patient into stable side position after the seizure stops, open and maintainclear airway.

7) Check for breathing. If absent, follow the guidelines for collapse.

8) Allow the patient to sleep under supervision at the end of the seizure.

9) On recovery, give reassurance.

10) The patient should not be sent home until fully recovered and they should be

accompanied.

11) Transfer to hospital if: first fit, repeat seizure, respiratory difficulty, patient suffered an

injury, tonic phase > 5minutes, post-seizure confusion > 5minutes.

12) If the patient remains unresponsive always check for ¶signs of life· (breathing and

circulation) and start CPR in the absence of signs of life or normal breathing




Chest pain/ Angina/ MyocardialChest pain/ Angina/ Myocardial

infarctioninfarctiony Symptoms and signs:

- Central chest pain, possble radiation to

left or right arms, jaw or neck.

- Nausea, vomitting.

- Restlessness.

- Shortness of breath.

- Pallor, cold sweaty skin.- Pump failure² hypotension, tarchycardia,

pulmonary edema.




y If acute myocardial infarction is suspected:- Reassure the patient, keep them warm.- Sit them up if breathless.- Lie them flat if they are faint.

- Give GTN tablets or spray.- Give high flow oxygen by face mask.

- Give 300 mg Aspirin.- Continue monitoring level of conscious.

- If unconscious, initiate collapse guidelines.Check for signs of life (breathing and

circulation) and initiate CPR



Foreign body/ upper airwayForeign body/ upper airway

obstructionobstruction

y Severe or complete upper airway

obstruction can progresses to

unconsciousness and cardiac arrest within

minutes.

y Presentations: distress, choking, coughing,

cyanosis, loss of consciousness.




y Partial obstruction:- Encourage patient to cough up or spit out.

y Complete obstruction:

- Sit patient up, turn patient side on in chair.

support chest with one hand and deliver 5sharp back blows between the shoulder blades

with the heel of the other hand.

- If fail, five abdominal thrusts (Heimlich).

y If unconscious:- Commence CPR with finger sweep between

each cycle.

- Consider cricothyroidotomy if no air entry.



HyperventilationHyperventilation

y Prolonged rapid deep breathing in very anxious

patient can lead to profound metabolic changes

that may result in loss of consciousness. A fall in

arterial CO2 concentration causes cerebralvasoconstriction and respiratory alkalosis.

y Presentations: tingling of fingers and lips,

dizziness and tetanic spasm of the peripheries.

Unconsciousness can happen due to relativecerebral hypoxia.




1) Reassure the patient and encourage patient to slow theirbreathing.

2) Do not use any bag for re-breathing. This can be dangerous and

only be used under medical direction.

3) The same benefits can be obtained more safely from deliberatelyslowing down the breathing rate by counting or looking at the

second hand on a watch. This is often referred to as "7-11

breathing", because a gentle inhalation is stretched out to take 7

seconds (or counts), and the exhalation is slowed to take 11

seconds.

4) If unconscious, initiate collapse guidelines. Check for signs of life

(breathing and circulation) and initiate CPR.



Malaysian emergency telephone number has now

been integrated to a single number, 999.

Previously before October 2007,

999 - Police and Ambulance

994 - Fire Rescue991 - Civil Defence

112 - Mobile phone dailing



ReferencesReferences

y Medical Emergencies and Resuscitation,

Standards for Clinical Practice and Training for

dental practitioners and dental care

professionals in general dental practice,Resuscitation Council (UK) July 2006, revised

May 2008.

y New Zealand Code of Practice MedicalEmergencies in Dental Practice, March 2005.

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