2: Medical Emergencies and First Aid in the Dental Surgery

CHAPTER 2 Medical Emergencies and First Aid in the Dental Surgery

Risk assessment

Healthcare aims to improve the health of patients but can itself carry risks, so the first principle must be to do no harm (‘primum non nocere’ – from the Latin). Dentists and dental nurses can be involved in using local anaesthesia (LA) and conscious sedation, procedures that are safer than general anaesthesia (GA), which is now only carried out in hospitals with critical care facilities. Most dental procedures are safe, although surgical procedures may be less safe. Patients with medical problems are generally more likely to have complications, including emergencies, than are healthy individuals. Thus a non-invasive procedure such as applying a fissure sealant on a healthy child, is likely to be far safer than, for example, a surgical operation in an older person with a heart by-pass who is being treated with anticoagulants (Box 2.2).

The taking of a medical history aims to elicit such risks, following which steps are then taken to reduce the risks (Table 2.1).

TABLE 2.1 Operative Risk Assessment and Management

Risks Increased by Risks Reduced by
Increasing age Planning treatment properly
Medical treatments Non-invasive procedures
Surgical treatments Monitoring
Lengthy dental procedures Reassurance
Drug use – medication or recreational  

Medical history

The relevant medical history (RMH) taken by the clinician includes any past medical and surgical problems. Patients are also asked if they carry a medical warning card or device. Careful note should be taken of it, particularly in respect of corticosteroid or warfarin use, a bleeding disorder or diabetes. It is far more helpful to be aware of a medical condition before undertaking dental treatment for a patient than trying to find out that history during an emergency. For example, managing a fit in a known epileptic person is far easier and less stressful for staff than managing a fit in a person not known to be epileptic. In the latter situation, there can be considerable uncertainty about what could be causing the problem and what is happening.

The relevance of many common medical conditions is discussed in Chapter 17. An easy to recall alphabetical list for the RMH is shown in Table 2.2.

TABLE 2.2 Relevance of Medical History to Dentistry

Condition Relevance in Dentistry
Allergies These range in severity from a localised rash to collapse from anaphylaxis. Common allergies are to LIED (see p. 7). Anaesthetics, analgesics (e.g. aspirin or codeine) and antibiotics (e.g. penicillin) and latex are the main offending agents
Bleeding disorders Bleeding and/or bruising are a significant hazard to any surgery
Cardio-respiratory disorders Wheezing, cough, shortness of breath (dyspnoea), chest pain, swelling of ankles, palpitations, hypertension may be a contraindication to GA or conscious sedation
Drug treatment Drug use may be the only indication of serious underlying disease. Treatment will need to be deferred until the drugs are identified.
Most serious interactions with drugs or herbal medicines are with GA or conscious sedation agents.
Aspirin and other similar drugs may be a hazard in anticoagulated, asthmatic, diabetic or pregnant patients, those with peptic ulcers, or children under 16 years.
Recreational drugs may cause behavioural problems.
Endocrine disorders Diabetes mellitus may lead to collapse. Hypoglycaemia (low blood sugar) is the main problem
Fits or faints Fainting and epilepsy may result in injury to the patient
Gastro-intestinal disorders Crohn’s disease or coeliac disease may have oral complications such as ulceration, and gastric disorders may increase the risk of vomiting during GA or conscious sedation
Hospital admissions and attendances Hospital admissions may indicate presence of a disease
A history of operations may provide knowledge of possible reactions to GA, sedation and surgery
Operations on the retina (part of the eye) may use intraocular gases and such history would be a contraindication to GA or conscious sedation, which may cause rapid expansion of the ocular gas, leading to blindness
Infections The transmissibility of infections must be considered. People who have attended a clinic for sexually transmitted infections (STI), or been admitted to hospital for an infection, or who have been refused for blood donation may be at risk. Carriers of meticillin-resistant Staphylococcus aureus (MRSA), tuberculosis, or of Neisseria meningitidis may be a particular hazard to others
Jaundice and liver disorders A history of jaundice or other liver disease may mean the patient is prone to prolonged bleeding or impaired drug metabolism, and may imply carriage of hepatitis viruses
Kidney and genitourinary disorders Excretion of some drugs may be impaired. Tetracyclines should be avoided or given in lower doses
Likelihood of pregnancy Any essential procedures involving drugs (even aspirin), elective operative dentistry (restorative or surgical), radiography or GA should be arranged during the middle trimester
Mental state Anxiety is common before dental treatment. Anxious patients may sometimes react aggressively, and anxiety may limit extent of dental treatment that can be provided under LA
Neurological Movement disorders can significantly disrupt operative procedures

Role of the dental nurse in a medical emergency

According to the General Dental Council (p. 71), dental nurses should be:

The most important tool that you, as a dental nurse, will have in any emergency is the ability to remain calm and focused. By keeping your knowledge up to date and practising procedures, you can ensure that you will act effectively and confidently during any emergency. Crucial to this is:

The emergency kit

The emergency kit should consist of the equipment and drugs listed in Table 2.3. Where possible all emergency equipment should be meant for single use only and latex-free to avoid allergies. Note that the recommended kit includes only drugs meant for injecting into the muscles (intramuscular, short form: IM) and not into veins (intravenous, short form: IV).

TABLE 2.3 Suggested Minimal Equipment and Drugs for Emergency Use in Dentistry

Equipment Comments
Portable apparatus for administering oxygen Portable oxygen cylinder (D size) with pressure reduction valve and flow meter. The cylinder should be of sufficient size to be easily portable and also to allow for adequate flow rates, e.g. 10 litres per minute, until the arrival of an ambulance or the patient fully recovers. A full D size cylinder contains 340 litres of oxygen and should allow a flow rate of 10 litres per minute for up to 30 minutes. Two such cylinders may be necessary to ensure oxygen supply does not fail
Oxygen face mask with tube
Basic set of oropharyngeal airways (sizes 1, 2, 3 and 4)
Pocket mask with oxygen port
Self-inflating bag valve mask (1 litre size bag) for use by staff who 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. the Yankauer sucker
Spacer device for inhalation of bronchodilators  
Automated external defibrillator (AED)  
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 gauge)
Drugs as below  
Emergency Drugs Required (Dosage Given is for Adults)
Anaphylaxis Intramuscular adrenaline (0.5 ml of 1 in 1000 solution; repeat at five minutes if needed)
Hypoglycaemia Oral glucose solution/tablets/gel/powder (proprietary non-diet drink or 5 g glucose powder dissolved in water) – for example, GlucoGel, formerly known as Hypostop gel (40% dextrose)
  Glucagon injection (intramuscular 1 mg) – for example, GlucoGel, GlucaGen, HypoKit
Acute exacerbation of asthma Beta 2 agonist – for example salbutamol aerosol inhaler (100 micrograms/activation, activations directly or up to six into a spacer)
Status epilepticus Midazolam (10 mg) (buccal or intranasal use)
Angina Glyceryl trinitrate (GTN)* (two sprays of 400 micrograms/metered activation)
Myocardial infarction Dispersible aspirin (300 mg chewed)

No corticosteroid is included.

Other agents (e.g. flumazenil) and equipment (e.g. pulse oximeter) are needed if conscious sedation is administered in the surgery.

* Do not use nitrates to relieve an angina attack if the patient has recently taken sildenafil (e.g. Viagra or Cialis) as there may be an abrupt fall in blood pressure; analgesics should be used.

This is because IM injections are generally easier and safer to give. IM injections are best given into the side of the thigh.

Basic life support

Regardless of the nature of an emergency, the first aim of managing it is to ensure basic life support (BLS), that is, adequate oxygenation and maintenance of adequate airways and blood pressure. The standard, well-tested approach to BLS (called the primary survey) includes:

and

In the UK, the Resuscitation Council is responsible for providing guidelines for how to carry out CPR. The BLS sequence described below is based on the UK Resuscitation Council Resuscitation Guidelines (2005). Box 2.3 provides an aide mémoire for adult BLS.

Adult BLS Sequence (Figure 2.1)

4. Keeping the airway open, look for chest movement and check if the person is breathing normally by listening near their mouth for breath sounds and feeling for air on your cheek (Figure 2.1C). Do this only for about 10 seconds – if you have any doubt, act as if the breathing is not normal. Remember that in the first few minutes after a cardiac arrest (when the heart stops beating; see p. 50), a person may be barely breathing, or may be taking infrequent, noisy, gasps (do not confuse this with normal breathing).
8. (A) Start combined compression and mouth-to-mouth breathing:

Place a mouthpiece (Figure 2.1G) around the mouth, ensuring the seal is good.
Jan 8, 2015 | Posted by in Dental Nursing and Assisting | Comments Off on 2: Medical Emergencies and First Aid in the Dental Surgery
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