the management of medical emergencies in dental practice emergencies in dental practic… ·...
TRANSCRIPT
The management of medical
emergencies in dental practice
Jon White
Senior Resuscitation Officer
Milton Keynes Hospital NHS Foundation Trust
Learning outcomes
Examine the incidence of serious medical
emergencies in dental practice
Highlight current guidelines and
professional responsibilities
Discuss assessment strategies and key
management points of common medical
problems
Incidence of serious medical
problems in dental practice
Rare
‘0.7 cases per dentist per year’ (Girdler, N. 1999)
Vasovagal episodes most common
Hypoglycaemia, angina, seizures, choking
and anaphylaxis less common
Myocardial infarction and cardiac arrest
extremely rare
The General Dental Council (2005)
Medical emergencies can occur at any
time
All members of staff need to know their role
in the event of a medical emergency
Members of staff need to be trained in
dealing with such an emergency
Dental teams should practice together in
simulated emergency situations
Current guidelines
Medical emergencies and resuscitation:
Standards for clinical practice and training
for Dental Practitioners and Dental Care
Professionals (Resuscitation Council (UK), 2006)
http://www.resus.org.uk/pages/MEdental.pdf
Principles
Well consulted and endorsed by the GDC
Describes the dentists responsibilities, and those of the dental team
Interesting inclusions
• ABCDE
• Simplified range of drugs with nothing IV
• Intranasal/buccal Midazolam
• Automated External Defibrillators (AED’s)
Compliance. You will need…
Regular training(for all staff)
Appropriate equipment(checked regularly)
A plan(who does what)
Basic principles of managing an
emergency
Think about safety at all times
Assess logically and efficiently and reassess
regularly
Deal with problems as you find them with
simple interventions
Ensure that appropriate help is called
Use ABCDE to gather information, structure
handovers and as a documentation template
Assessment
Head to toe examinationExposure
AVPU? Blood sugarDisability
Pulse, perfusion, colourCirculation
Rate, effort, noise, colourBreathing
Clear? Open?Airway
ABCDE assessment
Breathing
Circulation
Disability
Talking = ok
AirwayNot talking = not ok Open the airway
Breathing rate / min
Work of breathing and noises?
Heart rate / min
Blood pressure and/or capillary refill
Level of consciousness (AVPU)
Blood sugar
Exposure Head to toe examination
Give
O2
Normal values (adults)
Breathing rate: 12 – 20 / minute
Heart rate: 60 – 100 / minute
Blood pressure > 90 mm hg (systolic)
Capillary refill < 2 seconds
Blood sugar > 4 mmols
Level of
consciousness A&V P&U ×
Medical emergencies
Common conditions
Asthma
Anaphylaxis
Chest pain
Seizures
Hypoglycaemia
Syncope
History
Severity
ABCDE
Management
Asthma – History?
Recent or current cough or cold
Recent or current oral steroids
Admission to hospital in the last year
Admission to Intensive Care Unit
Asthma - Severity
Acute severe asthma
• Unable to complete sentences in one breath
• Respiratory rate > 25
• Heart rate > 110
Life-threatening asthma
• Cyanosis or respiratory rate < 8
• Heart rate < 50
• Exhaustion, confusion or ↓LOC
Asthma - Assessment
ABCDE?
Asthma - Management
Position patient appropriately
Administer high flow Oxygen (10 litres/min)
Administer inhaled Salbutamol, ideally
using a ‘spacer’
Call an ambulance if the patient does not
respond rapidly to treatment
COPD?
Anaphylaxis – History?
Known allergies
Previous reactions to LA, antibiotics or
latex
Anaphylaxis - Severity
New ABC problems need treatment with IM
Adrenaline
• Facial swelling, stridor, hoarse voice
• Increased shortness of breath or wheeze
• ↑HR and ↓BP (or signs of poor perfusion)
Mild reactions?
Anaphylaxis - Assessment
ABCDE?
Anaphylaxis - Management
Position patient appropriately
Administer high flow Oxygen (10 litres/min)
Administer intramuscular Adrenaline 0.5
mg (1:1000) if new A, B or C problem
Call an ambulance
Consider inhaled Salbutamol if wheeze
present
Chest pain – History?
Individuals with exert ional (stable) angina
may experience chest pain as a result of
dental treatment
Patients with a recent history of admission
to hospital with angina not associated with
exertion or stress (unstable) should be
referred for dental treatment
Chest pain - Severity
Any pain in the chest should be presumed
to be cardiac in origin
Stable angina that responds to GTN should
probably not cause concern
An ambulance should be called to those
patients with atypical pain or pain that
starts without a trigger
Chest pain - Assessment
ABCDE?
Chest pain - Management
Position patient appropriately
Administer high flow Oxygen (10 litres/min)
Call an ambulance
Administer sublingual Glyceryl trinitrate (2
tablets or 2 puffs)
Administer Aspirin 300 mg orally, crushed
or chewed
Seizures – History?
Form an opinion about how well controlled the patients seizures are
Any change in seizure pattern or a change in medication are significant factors
Be prepared
• What is their seizure like?
• Are there any precipitating factors?
• Do they get an aura?
Seizures - Severity
An ambulance should be called if…
Atypical seizure or status epilepticus
First seizure
Incomplete recovery after a seizure
Injury during a seizure
Seizures - Assessment
ABCDE?
Seizures - Management
Protect the patient from harm during a seizure
Administer high flow Oxygen (10 litres/min)
Do not attempt to insert anything in the patients mouth during the seizure
If the seizure last more than 5 minutes medication will be necessary
Buccal or intranasal Midazolam 10 mg?
Hypoglycaemia – History?
Insulin dependent (Type 1) diabetics are more likely to have hypoglycaemic episodes
Patients that describe poor control of their condition or a lack of awareness are the highest risk group
Non diabetic individuals can be hypoglycaemic!
Hypoglycaemia - Severity
Hypoglycaemic individuals generally
respond promptly to glucose and/or IM
Glucagon
An ambulance should be called to those
individuals that do not respond to these
treatments
Hypoglycaemia - Assessment
ABCDE?
Hypoglycaemia - Management
Conscious and cooperative?
Give Glucose orally
Uncooperative and/or ↓LOC?
Manage patient safely
Administer Glucose gel buccaly and/or IM
Glucagon 1 mg
Observe for response to treatment
Syncope – History?
Some individuals will report regular or
frequent ‘faints’
Have they been investigated?
Syncope – Is it?
Probably Syncope Possibly not Syncope
No clear precipitating
factorOther symptom/signs
Sudden loss of
consciousness
More gradual reduction
in level of consciousness
Prompt recoverySlow or no recovery or
deteriorates further
Syncope - Assessment
ABCDE?
Syncope - Management
Position patient appropriately
Administer high flow Oxygen (10 litres/min)
Observe closely
Questions?
Summary
Be prepared
Be calm
Be safe