Introduction

A medical emergency is an injury or illness that poses an immediate threat to a person’s life or long-term health. Box 2.1 lists the warning signs of a medical emergency that you may encounter as a dental nurse.

Emergencies are best prevented where possible. Since emergencies are more likely to occur in people with existing medical problems, the clinician will take a medical history so that they are as forewarned as possible.

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

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

Managing a medical emergency

• All dental practices are required to have an emergency kit readily available.

All practices should have a designated first responder. Depending on the severity of the emergency, a trained first aider, a dental nurse or a clinician may be the most appropriate person to act as first responder.

The first responder should designate a specific person to call the emergency services. Another person should be sent to wait for the arrival of the emergency services and direct them to the location of the emergency.

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

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.

BOX 2.3 Summary of Basic Life Support

1. Check whether the patient is conscious or unresponsive

• If conscious: monitor

• If unresponsive: shout for help.

2. Check breathing

• If breathing (conscious or unresponsive): monitor

• If not breathing:

Call the emergency services, e.g. 999

Give 30 chest compressions

Give two rescue breaths using a mouthpiece

Give 30 chest compressions

Continue the above until help arrives.

Adult BLS Sequence (Figure 2.1)

1. Make sure the person having the problem, any other people around, and you are safe.

2. Check if the person is responsive. Gently shake them by their shoulders and ask loudly, ‘Are you all right?’

3. (A) If the person responds:

• Leave them in the position in which they already are, provided there is no further danger.

• Try to find out what is wrong with them and get help if needed.

• Reassess them regularly.

(B) If the patient does not respond:

• First of all shout for help.

• Then lay the person on their back and open the airway by tilting their head backwards and lifting their chin (Figure 2.1A,B).

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).

5. Ask someone to call for an ambulance or, if you are on your own, do this yourself. You may need to leave the person to do this.

6.(A) If the person is breathing normally now, turn them into the recovery position (Figure 2.2) and check again that they are breathing.

(B) If the person is not breathing normally go to step 7.

7. Start chest compression:

• Kneel by the side of the person

• Place the heel of one hand in the centre of the person’s chest.

• Place the heel of your other hand on top of the first hand.

• Interlock the fingers of your hands and ensure that you are not applying pressure on the person’s ribs, the upper abdomen or the bottom end of their sternum (breastbone) (Figure 2.1D).

• With your arms straight, press down 4–5 cm on the sternum.

• Then release all the pressure on the chest but do not lift your hands from the sternum. Repeat the action at a rate of about 100 times a minute (which means almost but not quite two full compressions in one second) 30 times. Release for the same amount of time as compressing the chest.

• After 30 compressions open the airway again by tilting the head and chin and move to step 8.

8. (A) Start combined compression and mouth-to-mouth breathing:

• Close the person’s nose by pinching the soft part with the index finger and thumb of your hand which should rest on their forehead (Figure 2.1E).

• Let the person’s mouth open, but make sure the chin is still lifted (Figure 2.1F).

• Place a mouthpiece (Figure 2.1G) around the mouth, ensuring the seal is good.

• Take a normal breath and blow steadily into the person’s mouth. At the same time watch for their chest to rise; an effective rescue breath will take about one second to make the chest rise as in normal breathing.

• Still maintaining the head and chin lift, take your mouth away and check whether the chest falls as air comes out.

• Repeat the process by taking a normal breath to give another effective rescue breath, and without any delay perform another 30 chest compressions, with your hands on the correct position on the sternum.

• Continue with chest compressions and rescue breaths in a ratio of 30:2.

• Do not stop unless the person starts breathing normally. However, you should not try to attempt more than two breaths before returning to chest compressions. If there is more than one rescuer present, switch between rescuers every two minutes to prevent fatigue and for minimum delay during the changeover.

FIGURE 2.1 Cardiopulmonary resuscitation (CPR) on a child of 8 years or older or an adult. (A) Lay the person down on a hard, flat surface. Put on disposable gloves and check their mouth and throat to ensure that no object is present. If there is, try to sweep it out with your fingers. If the person vomits, turn them on their side and sweep the vomit out of the mouth with two fingers. If the person is rigid or having a seizure, do not try the above. (B) Place one hand on the forehead to tilt the head backwards and place your fingertips under the point of their chin to tilt it to open the airway. (C) Look, listen and feel. If the person is at all responsive (if he or she is moaning, breathing, blinking, or moving any part of the body), his or her heart is beating, do not perform steps 6 or 7. (D) Position yourself vertically above the person’s chest to perform chest compression (see text for details). (E, F) Performing mouth-to-mouth resuscitation. (G) A mouthpiece.

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Related

Related posts:

1. 16: Dental Emergencies
2. 12: Dental Drugs, Materials, Instruments and Equipment
3. 4: Anatomy and Physiology
4. 5: Oral Disease
5. 10: Surgical Procedures
6. 17: Human Diseases and Health Promotion

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