• Ensure access to appropriate drugs and equipment
This chapter is focused on the main diagnostic and management issues in emergency management; fuller discussion of these conditions may be found in the relevant chapters and the controversies in this area are discussed in the references. The expanded knowledge base of medicine, and effective new technologies, techniques and drugs have allowed patients, who in earlier times would have succumbed, to remain alive and live to much greater ages; such patients in particular may be prone to medical emergencies. Collapse and other emergencies are a cause of concern for all involved (Box 1.1).
In general terms, health-care professionals (HCPs) should develop strategies to identify patients at risk of emergencies, assess the severity of those risks and, where necessary, recognize the need for help and be able to seek advice from a colleague with special competence in the relevant fields. All need to contend with the increasing variety of medical problems, particularly as they are aware that they face a growing risk of litigation if they do not keep themselves familiar with current knowledge, in line with the increasing acceptance of the need for continuing professional development (CPD).
There are few randomized controlled trials (RCTs) available to provide evidence for the various practices, and so many of the recommendations have to be based on consensus. The comments and recommendations herein should be used as guidelines to care, not commandments.
Annual theoretical and practical training of all clinical staff is required. Clinical staff have an obligation to be conversant with the current Resuscitation Council (UK) guidelines (2012) (see Further reading). The UK General Dental Council (GDC), in Standards for the dental team (2013), states that all dental professionals are responsible for putting patients’ interests first and for acting to protect them. Central to this responsibility is the need to ensure that HCPs are able to deal with medical emergencies that may arise. All members of the dental team need to know their roles in the event of an emergency. The GDC guidance, Principles of dental team working (2005), states that dental staff who employ, manage or lead a team should make sure that:
■ there are arrangements for at least two people to be available to deal with medical emergencies when treatment is planned to take place
■ all members of staff, not just the registered team members, know their role if a patient collapses or there is another kind of medical emergency
■ all members of staff who might be involved in dealing with a medical emergency are trained and prepared to deal with such an emergency at any time, and regularly practise simulated emergencies together.
The GDC has stipulated that 10 hours of training and retraining in emergency management is a mandatory requirement of CPD in every 5-year period.
Emergencies are rare. A medical emergency occurring in dental practice is most likely to be the result of an acute deterioration of a known medical condition. It may pose an immediate threat to an individual’s life and needs rapid intervention. It is best prevented! The most common medical emergency is the simple faint. Other common emergencies include fitting in an epileptic patient, angina pectoris (ischaemic chest pain), hypoglycaemia in a diabetic patient and haemorrhage. Myocardial infarction and cardiopulmonary arrest are more immediately dangerous (Box 1.2).
Emergency management algorithms are of paramount importance and dental employers are ultimately responsible for the performance of their staff as regards delivery.
Confidence and satisfactory management of emergencies can be improved by the following measures:
■ Repeatedly assessing the patient whilst undertaking treatment, noting any changes in appearance or behaviour.
■ Never practising dentistry without another competent adult in the room.
■ Always having accessible the telephone numbers of the emergency services and nearest hospital accident and emergency department. Details of the patient’s general medical practitioner should be recorded in the notes.
■ Training staff in emergency service contact protocols and emergency procedures. This should be repeated annually. All clinics should have a defined protocol for how the emergency services are to be alerted. The protocol should include clear directions to enable the emergency services to locate and access the clinic. In a large building, a member of the team should meet the emergency services at the main entrance.
■ Having a readily accessible emergency drugs box and equipment that is checked on a weekly basis (Tables 1.1 and 1.2; Figs 1.1–1.3).
■ Taking a careful medical history, assessing disease severity, scheduling and planning treatment carefully, and, in some cases, administering medication prior to treatment.
■ Using the simple intervention of laying the patient supine prior to giving local analgesia/anaesthesia (LA). This will prevent virtually all simple faints.
■ Ensuring that diabetic patients have had their normal meals, medication has been appropriately administered, and treatment is given early in the morning session or immediately after lunch. These measures are likely to prevent most hypoglycaemic collapses.
Suggested minimal equipment for emergency use in dentistrya
|Oxygen (O2) delivery||Portable apparatus for administering oxygen||Two portable oxygen cylinders (‘D’ size) with pressure reduction valves and flow meters. Cylinders should be of sufficient size to be easily portable but also to allow for adequate flow rates (e.g. 10 L/min), until the arrival of an ambulance or full recovery of the patient. A full ‘D’ size cylinder contains 340 L of oxygen and should allow a flow rate of 10 L/min for up to 30 min. Two such cylinders may be necessary to ensure the oxygen supply does not fail|
|Oxygen face mask (non-rebreathe type) with tube|
|Basic set of oropharyngeal airways (sizes 1, 2, 3 and 4)|
|Pocket mask with oxygen port|
|Self-inflating bag valve mask (BVM; 1-L size bag), where staff have been appropriately trained|
|Variety of well-fitting adult and child face masks for attaching to self-inflating bag|
|Portable suction||Portable suction with appropriate suction catheters and tubing (e.g. Yankauer sucker)|
|Spacer device for inhalation of bronchodilators|
|Automated external defibrillator (AED)||All clinical areas should have immediate access to an AED (collapse-to-shock time<3 min)|
|Automated blood glucose measuring device|
|Equipment for administering drugs intramuscularly||Single-use sterile syringes (2-mL and 10-mL sizes) and needles (19 and 21 sizes)||Drugs as in Table 1.2|
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Suggested minimal drugs for emergency use in dentistrya
|Emergency||Drugs required||Dosages for adults|
|Anaphylaxis||Adrenaline (epinephrine) injection 1:1000, 1 mg/mL||Intramuscular adrenaline (0.5 mL of 1 in 1000 solution)|
|Repeat at 5 min if needed|
|Hypoglycaemia||Oral glucose solution/tablets/gel/powder (e.g. GlucoGel®, formerly known as Hypostop® gel [40% dextrose])||Proprietary non-diet drink or 5 g glucose powder in water|
|Glucagon injection 1 mg (e.g. GlucaGen HypoKit)||Intramuscular glucagon 1 mg|
|Acute exacerbation of asthma||(β2 agonist)||Salbutamol aerosol|
|Salbutamol aerosol inhaler 100 mcg/activation||Activations directly or up to six into a spacer|
|Status epilepticus||Buccal or intranasal midazolam 10 mg/mL||Midazolam 10 mg|
|Angina||Glyceryl trinitrateb spray 400 mcg/metered activation||Glyceryl trinitrate, two sprays|
|Myocardial infarct||Dispersible aspirin 300 mg||Dispersible aspirin 300 mg (chewed)|
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aAfter Resuscitation Council (2012). No corticosteroid is included.
bDo not use nitrates to relieve an angina attack if the patient has recently taken sildenafil, as there may be a precipitous fall in blood pressure; analgesics should be used. Where possible, all emergency equipment should be single-use and latex-free. The kit does not include any intravenous injections.
All this is even more important when conscious sedation (CS) is used, when invasive or painful procedures are planned, or when medically complex individuals are being treated. ‘Forewarned is forearmed,’ and dental professionals must ensure that medical and drug histories are updated at each visit prior to initiating treatment. It is suggested that disease severity should be assessed using a risk stratification system – for example, the American Society of Anesthesiologists (ASA) classification (Chs 2 and 3) – as this may help identify high-risk individuals.
Few emergencies can be treated definitively in the dental clinic. The role of the dental team is one of support and considered intervention using algorithms that can ‘do no harm’. Previously, it has been suggested that 20 or more drugs should be available to the dental professional for the management of emergencies but this is impractical, may be a source of confusion and, if a drug is incorrectly administered, may be life-threatening.
The Resuscitation Council recommendations for equipment and drugs are detailed in Tables 1.1 and 1.2. Other agents (e.g. the midazolam antagonist flumazenil) and equipment (e.g. a pulse oximeter) are needed if CS is administered.
General anaesthesia (GA) must be undertaken only by anaesthetists and where advanced life support (ALS) is available.
Resuscitation and Emergencies
The GDC does not have any guidelines on resuscitation but would refer registrants to the Resuscitation Council, which does have relevant guidance. Full details are available at www.gdc-uk.org/Dentalprofessionals/Standards/Pages/home.aspx (accessed 30 September 2013).
The GDC’s Principles of dental team working (2005) covers medical emergencies.
For all medical emergencies, a structured approach to assessment and reassessment prevents any symptoms and signs being missed and any incorrect diagnoses being made. The sequence is best remembered as ‘ABCDE’ (Box 1.3). ‘Drs ABC’ highlights the sequence:
■ danger (recognizing an emergency)
■ respiration (establishing an airway)
People who collapse should be put in the ‘recovery position’ to maintain a clear airway UNLESS there could be a neck injury, such as after a fall or road traffic accident.
Dental staff should be trained in basic cardiopulmonary resuscitation (CPR) so that, in the event of cardiac arrest, they should be able to:
■ recognize cardiac arrest (the heart stops beating)
■ summon immediate help (dial for the emergency services)
■ initiate CPR according to current resuscitation guidelines (evidence suggests that chest compressions can be effectively performed in a dental chair)
■ ventilate with high-concentration oxygen via a bag and mask
■ apply an automated external defibrillator (AED) as soon as possible after collapse. Follow the machine prompts and administer a shock if indicated, with a maximum collapse-to-shock time of 3 minutes.
■ Assess the patient – ABCDE (as Box 1.3) – and give oxygen if appropriate
Monitor – reassess ABCDE regularly, attach an AED if appropriate
Oxygen – 15 L/min through a non-rebreathe mask
Verify – check that emergency services are coming
Emergency action – correct positioning and drug administration.
Intramuscular (i.m.) injection is used nowadays for giving most emergency drugs. The most accessible site in a clothed patient sitting in a dental chair is the lateral aspect of the thigh. There the vastus lateralis is a large muscle with no large nerves or arteries running through it. In an emergency, the injection can be administered through clothing. The mid-point between the pelvis and the knee is the preferred site.
The Advanced Medical Priority Dispatch System (AMPDS) is a unified system that sends appropriate aid to medical emergencies, including systematized caller interrogation and pre-arrival instructions. AMPDS works on the following response categories:
This may well be linked to a performance targeting system where calls must be responded to within a given time period. For example, in the UK, calls rated as ‘A’ on AMPDS aim to have a responder on scene within 8 minutes.
The ‘ABCDE’ approach to the sick patient
The ‘ABCDE’ approach to the sick patient is outlined at www.resus.org.uk/pages/MEdental.pdf by the UK Resuscitation Council (2006, updated 2012; accessed 30 September 2013). Appendix (i), which cannot be bettered, and states:
Dental Practitioners, Dental Care Professionals and their staff should be familiar with standard resuscitation procedures as recommended by the Resuscitation Council (UK). In all circumstances it is advisable to call for medical assistance as soon as possible by dialling 999 and summoning an ambulance.
Early recognition of the ‘sick’ patient is to be encouraged. Pre-empting any medical emergency by recognising an abnormal breathing pattern, an abnormal patient colour or abnormal pulse rate, allows appropriate help to be summoned, e.g. ambulance, prior to any patient collapse occurring. A systematic approach to recognising the acutely ill patient based on the ‘ABCDE’ principles is recommended. Accurate documentation of the patient’s medical history should further allow those ‘at risk’ of certain medical emergencies to be identified in advance of any proposed treatment. The elective nature of most dental practice allows time for discussion of medical problems with the patient’s general medical practitioner where necessary. In certain circumstances this may lead to a postponement of the treatment indicated or a recommendation that such treatment be undertaken in hospital.
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 reassess, starting with Airway, if there is further deterioration.
4. Assess the effects of any treatment given.
5. Recognise when you need extra help and call for help early. This may mean dialling 999 for an ambulance.
6. Use all members of your dental team. This will allow you to do several things at once, e.g. collect emergency drugs and equipment, dial 999.
7. Organise your team and communicate effectively.
8. 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.
9. Remember – it can take a few minutes for treatment to work.
10. The ABCDE approach can be used irrespective of your training and experience in clinical assessment 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.
■ In an emergency, stay calm. Ensure that you and your staff are safe.
■ Look at the patient generally to see if they ‘look unwell’.
■ In an awake patient ask, ‘How are you?’ If the patient is unresponsive, shake him and ask, ‘Are you all right?’ If they respond normally, they have a clear airway, are breathing and have brain perfusion. If they speak only in short sentences, they may have breathing problems. Failure of the patient to respond suggests that they are unwell. If they are not breathing and have no pulse or signs of life, start CPR according to current resuscitation guidelines.
Airway obstruction is an emergency.
1. Look for the signs of airway obstruction:
◆ Airway obstruction causes ‘paradoxical’ chest and abdominal movements (‘see-saw’ respirations) and the use of the accessory muscles of respiration, e.g. neck muscles. Central cyanosis (blue lips and tongue) is a late sign of airway obstruction. In complete airway obstruction, there are no breath sounds at the mouth or nose.
◆ In partial airway obstruction, air entry is diminished and usually noisy:
Inspiratory ‘stridor’ is caused by obstruction at the laryngeal level or above.
Expiratory ‘wheeze’ suggests obstruction of the lower airways, which tend to collapse and obstruct during expiration. This is most commonly seen in patients with asthma or chronic obstructive pulmonary disease.
Gurgling suggests there is liquid or semi-solid foreign material in the upper airway.
Snoring arises when the pharynx is partially occluded by the tongue or palate.
2. Airway obstruction is an emergency:
◆ In most cases, only simple methods of airway clearance are needed:
Airway opening manœuvres – head tilt/chin lift or jaw thrust.
Remove visible foreign bodies, debris or blood from the airway (use suction or forceps as necessary).
Consider simple airway adjuncts, e.g. oropharyngeal airway.
3. Give oxygen initially at a high inspired concentration:
◆ Use a mask with an oxygen reservoir. Ensure that the oxygen flow is sufficient (15 litres per minute) to prevent collapse of the reservoir during inspiration.
◆ If you have a pulse oximeter, titrate the oxygen delivery aiming for normal oxygen saturation levels (94–98%). In very sick patients this may not be possible and a lower oxygen saturation (more than 90%) is acceptable for a short period of time.
During the immediate assessment of breathing, it is vital to diagnose and treat immediately life-threatening breathing problems, e.g. acute severe asthma.
1. Look, listen and feel for the general signs of respiratory distress: sweating, central cyanosis (blue lips and tongue), use of the accessory muscles of respiration (muscles of the neck) and abdominal breathing.
2. Count the respiratory rate. The normal adult rate is 12 to 20 breaths per minute and a child’s rate is between 20 and 30 breaths per minute. A high, or increasing, respiratory rate is a marker of illness and a warning that the patient may deteriorate and further medical help is needed.
3. Assess the depth of each breath, the pattern (rhythm) of respiration and whether chest expansion is equal and normal on both sides.
4. Listen to the patient’s breath sounds a short distance from their face. Gurgling airway noises indicate airway secretions, usually because the patient cannot cough or take a deep breath. Stridor or wheeze suggests partial, but important, airway obstruction.
5. If the patient’s depth or rate of breathing is inadequate, or you cannot detect any breathing, use bag and mask (if trained) or pocket mask ventilation with supplemental oxygen while calling urgently for an ambulance.
6. Hyperventilation and panic attacks are relatively common in general dental practice. In most patients these will resolve with simple reassurance.
Simple faints or vasovagal episodes are the most likely cause of circulation problems in general dental practice. These will usually respond to laying the patient flat and, if necessary, raising the legs (see Appendix (ii) Syncope). The systematic ABCDE approach to all patients will ensure that other causes are not missed.
1. Look at the colour of the hands and fingers: are they blue, pink, pale or mottled?
2. Assess the limb temperature by feeling the patient’s hands: are they cool or warm?
3. Measure the capillary refill time. Apply cutaneous pressure for five seconds on a fingertip held at heart level (or just above) with enough pressure to cause blanching. Time how long it takes for the skin to return to the colour of the surrounding skin after releasing the pressure. The normal refill time is less than two seconds. A prolonged time suggests poor peripheral perfusion. Other factors (e.g. cold surroundings, old age) can also prolong the capillary refill time.
4. Count the patient’s pulse rate. It may be easier to feel a central pulse (i.e. carotid pulse) than the radial pulse.
5. Weak pulses in a patient with a decreased conscious level and slow capillary refill time suggest a low blood pressure. Laying the patient down and raising the legs may be helpful. In patients who do not respond to simple measures urgent help is needed and an ambulance should be summoned.
6. Cardiac chest pain typically presents as a heaviness, tightness or indigestion-like discomfort in the chest. The pain or discomfort often radiates into the neck or throat, into one or both arms (more commonly the left) and into the back or stomach area. Some patients experience the discomfort in one of these areas more than in the chest. Sometimes pain may be accompanied by belching, which can be misinterpreted as evidence of indigestion as the cause. The patient may have known stable angina and carry their own glyceryl trinitrate (GTN) spray or tablets. If they take these, the episode may resolve. If the patient has sustained chest pain, give GTN spray if the patient has not already taken some. The patient may feel better and should be encouraged to sit upright if possible. Give a single dose of aspirin and consider the use of oxygen.
(See Appendix (ii) Cardiac Emergencies.)
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.
1. Review and treat the ABCs: exclude hypoxia and low blood pressure.
2. Check the patient’s drug record for reversible drug-induced causes of depressed consciousness.
3. Examine the pupils (size, equality and reaction to light).
4. Make a rapid initial assessment of the patient’s conscious level using the AVPU method: Alert, responds to Vocal stimuli, responds to Painful stimuli or Unresponsive to all stimuli.
5. 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 (e.g. Glucogel; Dextrogel; GSF-syrup or Rapilose gel: see Appendix (ii) Hypoglycaemia) or glucose by other means.
6. Nurse unconscious patients in the recovery position if their airway is not protected.
To assess and treat the patient properly loosening or removal of some of the patient’s clothes may be necessary. Respect the patient’s dignity and minimize heat loss. This will allow you to see any rashes (e.g. anaphylaxis) or perform procedures (e.g. defibrillation).
See also Appendix 1.1 for the Resuscitation Council guidelines (2012) on dealing with common emergencies.
Collapse (Table 1.3)
The cause of sudden loss of consciousness may be suggested by the medical history:
■ Collapse at the sight of a needle or during an injection is likely to be a simple faint.
■ Following some minutes after an injection of penicillin, collapse is more likely to be due to anaphylaxis.
■ Collapse of a diabetic at lunchtime, for example, is likely to be caused by hypoglycaemia.
■ Collapse of a patient with angina or previous myocardial infarction may be caused by a new or further myocardial infarction.
|Actions; reassure patient and accompanying people, and|
|Emergency||Recognition||1. Call for assistance||2. Give oxygen 15 L/min||3. Other main actions||4. Alert emergency services|
|Anaphylaxis||Acute||Yes||Yes||Adrenaline (epinephrine) 500 mcg fo/>|