14

Medical Emergencies

Introduction

In the event of a patient becoming ill in the dental surgery, the dental team must be able to act quickly to help prevent the illness or injury from becoming worse. When a patient enters the surgery the full responsibility for his/her care, which includes health, safety and welfare, is in the hands of the dentist and the team. A patient may become ill at any time while in the surgery and this could be as a result of dental treatment or because of an existing condition. It is of utmost importance that the dental team is able to recognise signs and symptoms and act quickly and effectively in a potentially life-or-death scenario.

Legislation

• Management of Health and Safety at Work Regulations 1999:

  Employers should investigate the cause of medical emergencies/accidents which is an essential part of effective health and safety management and therefore forms part of the risk assessment process. The outcome of investigations could identify the need for additional controls.

• Health and Safety at Work, etc. Act 1974:

  Employers must ensure the health, safety and welfare of employees and others who may be affected by his activities.

• Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (1995) (RIDDOR):

  Requires certain incidents to be reported to the Health and Safety Executive (HSE) if they arise out of or in connection with the work being undertaken. Incidents must be reported which result in a fatality, or a member of the public being taken to hospital or suffering a major injury.

  Additional requirements for RIDDOR reporting are covered in Chapter 1.

Common Causes and Types

Common Causes

There are many reasons why a medical emergency may happen; however, the following are the most common:

• Patient anxious and nervous about the treatment and therefore feeling stressed
• Patient suffering from dental pain
• Patient suffering from physical exertion
• Patient not understanding or carrying out post-operative instructions
• Patient’s existing medical condition
• Patient abuse of drugs or alcohol
• Inadequate medical history obtained
• Medical history not routinely updated
• A reaction to local anaesthetic
• The result of an accident, for example, the patient swallowing or inhaling an endodontic instrument

Common Types

The common types of medical emergencies that are most likely to happen are listed below:

• Fainting (syncope), the most common
• Fainting during sedation
• Anaphylactic shock
• Diabetic hypoglycaemic
• Epileptic attack
• Cardiac arrest
• Stroke
• Shock
• Choking or difficulty with breathing
• Asthmatic attack
• Haemorrhage
• Burns/scalds

Minimise the Risk

Emergencies must be eliminated where possible; it is far better to avoid the occurrence than have to deal with it; the risk can be minimised in a variety of ways:

Reception

• Create a relaxed and pleasant atmosphere environmentally and personally.
• Be aware of patients’ apprehensions and communicate effectively to alleviate any fears.
• Give the patient your full attention.

Surgery

• Ensure surgery is well ventilated.
• Talk to the patient and give a brief explanation of the dental procedure.
• Ask the patient to remove heavy outer clothing.
• Check and update medical history.
• Ensure that preoperative instructions have been followed.
• Allow the patient to stop and interrupt the procedure.
• Observe and reassure the patient throughout.
• Provide efficient chair side support, for example, protect soft tissues, aspirate carefully and respond to patient’s needs.
• Observe the patient and be responsive to changes in his/her condition.
• Ensure that all post-operative instructions are given both verbally and in writing.
• Do not allow the patient to leave until he or she is fit to do so.

The whole of the dental team can be part of this procedure, which starts when the patient enters the reception area and is greeted by the receptionist and terminates when he/she is dismissed from the practice on the instruction of the dentist.

Managing Medical Emergencies

It is not always possible to eliminate an emergency even if you have carried out all procedures to minimise the risk. The dental team must be prepared to act if an emergency situation arises; a well-planned rehearsed routine saves lives. The dental setting should have an emergency drug kit that consists of the following (Source: Resuscitation Council (UK) revised June 2008):

• Emergency drug kit
  • Portable oxygen cylinder (D size) with pressure reduction valve and flow meter
  • Oxygen face mask with tubing
  • Basic set of oropharyngeal airways (sizes 1, 2, 3 and 4)
  • Pocket mask with oxygen port
  • Self-inflating bag and mask apparatus with oxygen reservoir and tubing (1-l size bag)
  • Variety of well-fitting adult and child face masks for attaching to self-inflating bag
  • Portable suction with appropriate suction catheters and tubing, for example, the Yankauer sucker
  • Single-use sterile syringes and needles
  • ‘Spacer’ device for inhaled bronchodilators
  • Automated blood glucose measurement device
  • Automated external defibrillator (AED)
  • For practices carrying out sedation – suction catheter sizes 6 and 10 French gauge (FG)

All staff must be familiar with the location of the equipment and it must be easily accessible. The location of the AED should be clearly marked with the UK Standard sign, rectangular in shape, white pictogram and text on a green background.

• Preparation
  • Emergency information is to be readily available.
  • Information is to be immediately accessible, placed next to telephone.
  • Emergency information includes emergency numbers/services, name, address, telephone number of practice, other useful numbers, that is, doctor and hospital.

• Staff training
  • All the team to be trained
  • Training updated routinely
  • Basic first aid and cardiopulmonary resuscitation (CPR) mandatory
  • Dental team to be competent to manage emergency situations
• Emergency routine
  • The team should establish routine and document.
  • Define specific roles in event of emergency.
  • Named person should be responsible for locating emergency kit.
  • Ensure emergency kit is accessible.
• Practise emergency routine
  • Practise regularly, 3 to 4 times a year.
  • Ensure staff are aware of and capable of specific roles.
  • Ensure that staff competently work as a team.
• Emergency drug kit
  • Store kit where it is readily available and easily accessible.
  • Appointed/trained person is responsible for kit.
  • Check supplies routinely, for example, expiry dates.
  • Maintain record of contents.
  • Replace used drugs immediately.
• Patient observation
  • Observe patient condition throughout treatment.
  • Be able to recognise vital signs, for example, pallor, breathing difficulties, pain.

Common Emergencies

This section provides an overview of the most likely cause, signs and symptoms and action to be taken in each situation. It should be noted that from time to time opinions change; therefore, it is vitally important that the dental team keeps up to date with these changes.

Fainting (Syncope)

The causes include reduced blood supply to the brain caused by anxiety, pain, hunger, fatigue, and high temperature.

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