Medical Emergencies

Medical Emergencies

Kathleen Fan, Syedda Abbas, Shariff Anwar, Nikolas Fanaras, Leandros Vassiliou, Rahul Jayaram, Andrew Ross and Suranjana Lahiri

Introduction

Medical emergencies can occur anywhere and at any time. As such the General Dental Council ‘Scope of Practice’ 2013 states: ‘A patient could collapse on any premises at any time, whether they have received treatment or not. It is therefore essential that all registrants are trained in dealing with medical emergencies, including resuscitation, and possess up to date evidence of capability’. Every dental practice or clinic has a duty of care to ensure an effective and safe service is provided for its patients (Jevon, 2012).

Chain of Survival

The occurrence of medical emergencies in dental practices is low, but importantly the survival from cardiac arrest is associated with the speed of resuscitation. The Chain of Survival (Figure 23.1) depicts the actions linking sudden cardiac arrest with survival (Nolan et al., 2010).

Illustration of chain of survival displaying line figures inside connecting circles depicting early recognition and call for help, CPR, defibrillation, and post resuscitation care.

Figure 23.1 The chain of survival. CPR, cardiopulmonary resuscitation.

Source: King’s College Hospital, London. Reproduced with the kind permission of the Resuscitation Council (UK).

The first link shows the importance of recognition of those at risk of cardiac arrest and calling for help in the hope that early treatment will prevent progression to cardiac arrest. The central links illustrate the integration of cardiopulmonary resuscitation (CPR) and defibrillation as the fundamental components of resuscitation. Immediate CPR can double or triple survival from out of hospital cardiac arrest due to ventricular fibrillation. Studies suggest that each minute delay in defibrillation reduces the probability of survival to discharge by 10–12% (Nolan et al., 2010). The final link of the chain shows the importance of postresuscitation care in the restoration of quality of life by preserving the function of, in particular, the brain and heart.

Medical Risk Assessment

Although medical emergencies can occur to anyone at any time, they are more likely to occur in certain patients. Ischaemic heart disease is the leading cause of death in the world and sudden cardiac arrest is responsible for more than 60% of adult death from coronary heart disease (Finegold, Asaria and Francis, 2001). Identification of these cases and other patients who are at higher risk of medical emergencies are essential as it may enable the prevention of emergencies occurring by modifying their treatment, e.g. a diabetic hypoglycaemic event, by carefully planning the time of their dental treatment to avoid impact on eating, anxiety and pain management in those with ischaemic heart disease.

Medical history taking is important each time the patient is seen to identify any changes that may have occurred. Patients with known epilepsy who report frequent convulsions or had a recent change in medical history would raise alarm bells of possible increased risk of an epileptic fit. It is important for the clinician to check with the patient even when paper or electronic medical histories have been given.

After completion of medical history taking it is possible to assign the patient to a physical risk category. The most commonly used scoring system is the American Society of Anesthesiologists Classification (ASA) and is a system originally set up to assess a patient’s fitness for surgery. The Resuscitation Council (UK) (2012) has suggested its use to help identify those at greater risk of a medical emergency during treatment and also provides guidance for selecting patients who would benefit from being referred for treatment within a hospital setting.

ASA 1: Normal healthy patient – no clinically important comorbidity and without clinically significant past/present medical history.
ASA 2: A patient with mild systemic disease.
ASA 3: A patient with severe systemic disease.
ASA 4: A patient with severe systemic disease that is a constant threat to life.
ASA 5: Moribund patients who are not expected to survive without the operation.
ASA 6: A declared brain dead patient who organs are being removed for donor purposes.

Patients with ischaemic heart disease, asthma, epilepsy, diabetes and allergies are potentially more at risk of developing medical emergencies in the dental clinic (ASA 2, 3 or 4 depending on the severity of the condition).

Teamwork

Teamwork is especially important during management of a medical emergency. It is important that each member of the team is aware of the situation. There should be a team leader (usually the senior dentist) who is making the decisions and delegating tasks to appropriate members of the team, e.g. getting the emergency kit, or calling for an ambulance. Effective communication is essential with clear requests for each task by the team leader and effective listening of individual team member response. Regular simulations of medical emergency situations within the practice will allow members for the team to practice their roles.

Calling an Ambulance

There will be a number of situations in dental practice when it will be necessary to call for an ambulance. It is useful to have a card near the telephone with the practice address for such times. On speaking to the emergency number operator tell them that you require the ambulance.

Once connected to the ambulance service:

  • Give details of the emergency, preliminary diagnosis (e.g. possible myocardial infarction).
  • Information about the patient (e.g. 65‐year‐old man, conscious, chest pain, blood pressure, pulse rate).
  • What is being done for the patient (e.g. oxygen is being given by face mask).
  • Provide exact address or location and telephone number from which the call is being made.
  • If appropriate stay on line and listen to important advice provided by the ambulance control officer.
  • Arrange for someone to meet the ambulance when it draws close.
  • Note the time that the call for emergency services was made (Haas et al., 2010, Jevon, 2013).

Resuscitation Council (UK) Standards

The Resuscitation Council (UK) updated its standard for primary dental care in 2013.

The key recommendations are:

  • All primary care dental facilities should have a process for medical risk assessment of their patients.
  • Specific resuscitation equipment should be available immediately in all primary care dental premises. This equipment list should be standardised throughout the UK.
  • All clinical areas should have immediate access to an automated external defibrillator (AED).
  • Each primary dental care facility should have a plan for summoning assistance in the event of a cardiorespiratory arrest (999 in the UK).
  • There should be regular practice and teaching using simulation‐based cardiorespiratory arrest scenarios.
  • Dental staff’s knowledge and skills in resuscitation should be updated at least once a year.

Assessment of the Sick Patient and the ABCDE Approach

The most important aspect regardless of condition is appropriate initial assessment according to basic life support guidelines. It is vital a systematic approach is followed for the assessment and management of a sick patient. This allows the clinician to stay as calm as possible and avoids missing important signs and the delivery of key treatment. Each step of the assessment should be made and immediate action taken where indicated. However, monitoring should be undertaken only after completion of steps A, B, C, D and E. Help should be called for at the earliest opportunity, whether this is the senior dentist or the emergency services.

The principle of the ABCDE approach is to provide a system which avoids missing life‐threatening pitfalls in patient management. Each step in the ABCDE approach is essential. The order of the categories was determined by the speed at which each one can precipitate devastating decline in the patient, i.e. if there is a problem with A (airway), it must be resolved as much as possible before addressing B (breathing) as failure to establish an airway precludes the possibility of successfully restoring respiration.

The ABCDE approach is used in all areas of emergency medicine, whether in medical, surgical or trauma scenarios. It provides structure to what can often seem to be a chaotic situation. It is simple and memorable and as can be seen in the following information, easily summarised and recalled. However, there is no substitute for attending dedicated courses in emergency care provided by qualified and experienced tutors.

A – Airway
Upper airway obstructions often carry characteristic presentations but can be silent. Shortness of breath caused by upper airway obstruction should be treated as an emergency.
Look and Listen for signs of airway
obstruction
  • Soft tissue swelling is possible with allergic reactions or infections (see also Anaphylaxis section).
  • Paradoxical chest and abdominal movement.
  • Cyanosis (late sign).
  • Gurgling – due to secretions.
  • Choking – foreign body.
  • Snoring – partial obstruction in patient with altered consciousness (sedation).
  • Stridor – an inspiratory ‘wheeze’ type noise pathognomonic of upper airway compromise.
  • Wheezing expiratory wheeze is usually caused by lower airway collapse commonly seen in patients with asthma or COPD.
  • Silent – total airway obstruction.
Act
  • Stop dental and other non‐urgent treatment.
Choking (Figures 23.2 and 23.3)
  • The airway can be opened by head tilt/chin lift or jaw thrust manoeuvres.
  • A visual inspection of the mouth and pharynx can be made and offending objects removed.
  • Remove debris and fluids using suction or forceps as appropriate.
  • Back blow and abdominal thrust if there is foreign body obstruction.
  • Give oxygen 15 l/min (via a reservoir bag) – or the highest flow available.
  • Consider an airway adjunct if the airway is not easily maintained, the patient can tolerate it and you can insert it confidently (e.g. an oropharyngeal/Guedel airway).
Monitor
  • Aim to maintain O2 saturations between 94 and 98%.
  • Consider that very sick patients or those with coexisting respiratory disease may not be able to achieve this.
  • Continue to observe for signs of improvement/worsening.
B – Breathing
Assessment includes counting respiratory rate and inspecting the patient for abnormal breathing.
Place your cheek over the patient’s mouth and looking down the body to the chest.
Respiratory rate (RR) (age dependent) – increased rates associated with initial distress but decreasing rates can indicate catastrophe! Normal rate 12–20 for adults and 20–30 for children (1–5 years) although this latter figure changes yearly in very young patients.
Look for:
  • Tachypnoea (RR >20) is the usually the first sign of respiratory distress.
  • Slow RR is also a worrying sign – may be a sign of oversedation or tiring.
  • Abnormal breathing patterns.
  • Symmetry of chest movements.
  • Depth of breathing.
  • Abnormal chest and abdomen movements with breathing. ‘Paradoxical’ movements refer to thrusting in and out of abdomen in time with attempted in‐ and expiration respectively.
  • Use of accessory muscles – this can be seen as tensing of shoulder and neck musculature and bracing of the shoulders often using the arms of a chair for example.
  • Cyanosis – bluish discolouration of mucous membranes precipitated by low circulatory oxygen concentrations.
  • Abnormal breath sounds on auscultation including unequal air entry, decreased air entry and wheeze.
Act
  • Continue monitoring (including pulse oximetry if available –normal 97–100% PaO2) and treating as for A (Airway).
  • Treat underlying course if possible, e.g. asthma beta‐2 agonist inhaler.
  • Failure of respiratory effort should be treated with CPR immediately (please see Cardiopulmonary Resuscitation section).
C – Circulation
Tachycardia is one of the most important markers of severity in acute shortness of breath. Emergencies originating from the cardiovascular system will be addressed in appropriate sections of this chapter. Simple faints and vasovagal episodes account for a great number of collapsing incidents and can be rectified by simple measures.
Look and Feel
  • Colour of the hands and face for:
    • Cyanosis (as above).
    • Temperature.
    • Clamminess.
  • Cool and clammy hands may be indicative of reduced blood pressure precipitating collapse.
  • The capillary refill time:
    • Can be measured by firmly pressing a patient’s finger (preferably whilst held at their heart level) for 5 s and upon release, monitoring the time for its colour to return to the surrounding colour.
    • This can also be done over the sternum if the peripheral circulation is suspected to be poor for other reasons.
    • A normal refill time is <2 s.
  • The pulse rate can be measured at the wrist (radial), neck (carotid) or groin (femoral) and should be assessed for:
    • Rate – as with breathing, a raised or lowered pulse rate provide parameters of measuring the patient’s condition.
    • Rhythm – pulse should be regular and a good knowledge of past medical history will allow the practitioner to assess whether an abnormal rhythm is acute in onset. A pacemaker or internal cardiac defibrillator can be quickly checked for and is usually found under the skin of the upper left anterior chest wall.
    • Volume – pulse volume is a crude assessment of circulation especially where the normal character is not known but can provide information regarding pulse pressure.
Act
  • Formally measure blood pressure. BP <90 mmHg suggests shock.
  • Lay the patient as flat as possible to minimise the required blood pressure needed to achieve cerebral perfusion. A slight head down positioning may be applied if possible (for low BP due to vasovagal or simple faint or anaphylactic shock).
  • Chest pain – sit patient up, consider glyceryl trinitrate, aspirin, O2 and call ambulance.
  • Continue airway and breathing management.
  • Consider high flow oxygen (15 l).
  • As with breathing, circulatory arrest is an indication for cardiopulmonary resuscitation.
Monitor
  • Blood pressure.
  • Pulse.
D – Disability
Refers generally to the conscious state of the patient and what may be affecting it.
Look and Listen
  • Responsiveness most easily be measured using the AVPU scale which represents severity of conscious impairment based on:
    • Alert – i.e. no conscious deficit, and an alert responsive patient.
    • Verbally responsive – i.e. the patient responds to verbal prompting, e.g. if their name is called.
    • Response to Pain – the patient is only roused by painful stimuli, e.g. pressure over the sternum or nail bed. This represents a quite serious loss of consciousness.
    • Unresponsive and clearly an extremely worrying state of consciousness.
  • Pupillary size and responsiveness to light can be measured and may be indicative or previous medication uses (pin point pupil –opiate drugs including illicit).
Act
  • Take measures to review medication history and possible causes of drug interactions and counteract if possible.
  • Measure blood glucose to exclude hypoglycaemia and give glucose supplement if required.
  • Review A B C to exclude hypoxia or hypotension as causes for altered level of consciousness.
  • Consider oxygen.
  • Consider call for ambulance.
E – Exposure
Exposure of the patient is the only way to be sure that no physical sign is missed and should be undertaken with the dignity of the patient second only to their health and safety. Exposure should not be prolonged to avoid unnecessary heat loss. Look for urticaria if anaphylaxis is considered.
Monitor Once full A, B, C, D and E assessment has been performed and maximal treatment given, the cycle should be started again and repeated until patient recovery or help arrives.
Image described by caption and surrounding text.

Figure 23.2 Management of choking. (a, b) Back blows. (c) Abdominal thrust.

Management of choking in paediatric patients. Paediatric back slap placing man’s left hand at the back of baby doll (left). Paediatric abdominal thrust using his right middle and index fingers (right).

Figure 23.3 Management of choking in paediatric patients. (a) Paediatric back slap. (b) Paediatric abdominal thrust.

Learning Points

  • The ABCDE approach provides a structured and safe approach to any medical emergency.
  • When in doubt it can always be turned to and provides simple and safe methods to assess and provide potentially lifesaving, simple treatments.
  • It can also provide reassurance in not so urgent situations.
  • It should be used in an ordered ABCDE fashion and repeated after each cycle ABCDE (clearly re‐exposure is unlikely to be necessary).
  • ABCDE provides a common language when communicating the condition of a patient to other healthcare professionals.

Respiratory Problems: Shortness of Breath

In the community, management of shortness of breath involves managing complications in patients with severe respiratory disease and other acute events. The medical history will identify patients with chronic respiratory symptoms in which their disease process may alter their dental management, e.g. severe chronic obstructive pulmonary disease requiring long‐term oxygen therapy, or heart failure (see later). These patients may suffer worsening shortness of breath during consultation or procedures. They will nevertheless require assessment in the same manner as a patient with acute symptoms.

General Assessment and Common Conditions

An outline of general respiratory conditions and their management is given here. If a history can be obtained, symptoms of wheeze, cough, chest tightness or shortness of breath can be specifically asked for and if present then further questioning can commence. This should include:

  • Timing of symptoms (e.g. morning or evening).
  • Other triggers (e.g. dust, pollen, cold weather, stress).
  • Drug reactions (e.g. to NSAIDs, aspirin, beta‐blockers).
  • Duration of symptoms.
  • Smoking history.
  • Occupational history.
  • Exercise tolerance.
  • Family history.

When presented with acute shortness of breath the most important task, regardless of condition, is appropriate initial assessment according to basic life support guidelines. Each step of the assessment should be made and immediate action taken where indicated, with monitoring undertaken only after completion of ABC (see the ABCBE approach described previously). Help should be sought at the earliest opportunity and emergency services called with the utmost urgency should the practitioner feel unable to cope with the situation in their facility.

Asthma

Asthma is an obstructive airway disease characterised by:

  • Acute, chronic and acute on chronic airway inflammation.
  • Symptoms of breathlessness and wheeze.
  • The wheeze of asthma is on expiration: this can help differentiate between it and upper airway obstruction/constriction.

There is no agreed definition of asthma. The International Consensus Report describes asthma as a chronic inflammatory disorder of the airways encountered in susceptible individuals with symptoms associated with widespread but variable airway obstruction and an increase in airway response to a variety of stimuli. Obstruction is often reversible, either spontaneously or with treatment. The following factors are recognised by the British Thoracic Society as being associated with a diagnosis of asthma:

  • Chemical or environmental triggers.
  • History of hypersensitivity/atopy, e.g. hay fever, eczema.
  • Emotional states including laughter, stress (particularly in children).
  • A family history of atopy or asthma (possibly the strongest predictor of disease).

In a patient with known asthma, a history of severity and frequency of symptoms as well as medication use is invaluable. Although not foolproof, a patient’s dependence on medication to achieve the symptoms profile they describe can provide a good barometer of disease severity.

With this knowledge, we must still assess each patient as an individual. Assessment of a patient with symptomatic shortness of breath includes:

  • Symptom evaluation by questioning the patient.
  • A, B, C assessment as described in the section on the ABCDE approach.
  • Prompt and effective examination of the respiratory system comprising:
    • Measurement of respiratory and heart rate (good indicators of breathlessness but must be taken in context).
    • Oxygen saturation monitoring.
    • Auscultation for breath sound abnormalities if equipment available and clinician confident to do so.
    • Peak flow measurement is a simple test to perform and most useful in a patient aware of their usual score (if available and the clinician is confident to interpret).

There are specific criteria to assess severity of an asthma attack (taken from British Thoracic Society, 2008 (revised 2012)):

  1. Moderate exacerbation:
    • Increasing symptoms.
    • Peak expiratory flow (PEF) 50–75% best/predicted.
    • No severe attack symptoms.
  2. Acute severe attack:
    • Inability to complete sentences.
    • Respiratory rate >25/min.
    • Tachycardia >110.
    • PEF 33–50% best/predicted.
  3. Life‐threatening attack:
    • Severe asthma symptoms +:–.
    • Cyanosis.
    • Bradycardia (heart rate <50 bpm).
    • Exhaustion and conscious level drop.
    • Oxygen saturations <92%.
    • Silent chest.
    • PEF <33% best/predicted.
    • Poor respiratory effort.

Treatment

Dental or other non‐urgent activities should be stopped and the patient placed in a comfortable seated position immediately, with prompt assessment using the ABCDE approach. Remove any objects or substances used in treatments including dental impression materials, mouth props, and rubber dams. It must be borne in mind that these may have precipitated symptoms whether caused by asthma, allergic reaction/anaphylaxis, pain or emotional distress. Check for a clear airway. Treatment then consists of oxygen therapy and attempts to reverse bronchospasm.

Oxygen
  • Fifteen litres of oxygen can be delivered through a reservoir bag and remains the mainstay of oxygen therapy particularly if monitoring in unavailable.
  • In a hospital setting, oxygen should be titrated to maintain saturations of 94–98% on pulse oximetry (carbon dioxide retention is discussed later). This does not mean that saturations above this necessitate removal of oxygen therapy.
Bronchodilators – a practical and readily available treatment plan is provided in the box opposite and the remainder of this subsection outlines the other potential management options as outlined by the British Thoracic Society and can be used as the experience and availability of resources to the practitioner allows.
  • In the absence of a nebuliser, the patient should be given up to 10 activations (puffs) of their salbutamol inhaler. A large‐volume spacer may be useful, especially with children. This can be repeated every 10 min.
  • Treatment may be initiated with two puffs and a further two puffs given every 2 min up to a maximum of 10 in 10 min. Ten puffs may now be given every 10  min in succession without the need to escalate by two puffs per 2 min.
Beta‐agonists (e.g. salbutamol) are often the staple of obstructive airway disease. Their actions on receptors are believed to cause:
  • Relaxation of bronchial smooth muscle.
  • Decrease in mast cell mediator release.
  • Inhibition of neutrophils, eosinophils and lymphocyte functional responses.
  • Increase mucociliary transport.
  • An effect on vascular tone and oedema formation.
  • Many patients will regularly use these medications.
The mode of bronchodilator delivery will be determined by the patient.
  • Mild attacks may be amenable to inhaler treatment as described above.
  • If there are concerns regarding this or the patient feels unable to do this then a spacer device may be used. The latter is especially relevant to children.
  • In more severe attacks, nebulised salbutamol 2.5 mg should be used as first‐line treatment (if available). This should be given even in the absence of supplemental oxygen. (A flow rate of 6 l/min is required to drive most nebulisers and it is important to be familiar with any equipment.) This would be given in the ambulance or in hospital as would any subsequent escalation in treatment.
Escalation of treatment would include:
  • Steroid treatment and nebulised ipratropium bromide.
  • If anything other than a moderate attack is suspected, or there are any further concerns, referral to the local Emergency Department should be made.

Observation and Further Management
  • Asthma describes a condition of reversible bronchoconstriction. Failure to achieve this with initial, simple measures should prompt escalation of treatment (Table 23.1). Refer to the local emergency department.
  • Continue treatment whilst awaiting assistance or transfer.
  • Oxygen and nebulised salbutamol if available.
  • Steroids in the form of oral prednisolone (in hospital).
  • Ipratropium bromide nebulisers, not to be given continuously (maximum frequency four per day) (in hospital).
  • Salbutamol may be given ‘back to back’ assuming no ill effects.

Table 23.1 Treatment ladder for asthma.

Step Adult Child aged 5–12 years Child aged 2–5 years
Step 1 Inhaled short‐acting beta agonist, e.g. salbutamol as required Inhaled short‐acting beta agonist, e.g. salbutamol as required Inhaled short‐acting beta agonist, e.g. salbutamol as required
Step 2
(patients requiring regular preventer therapy)
Inhaled corticosteroid (200–800 μg), e.g. beclometasone Inhaled corticosteroid (200–400 μg), e.g. beclometasone or
other preventer inhaler
Inhaled corticosteroid, e.g. beclometasone
or leukotriene antagonist, e.g. montelukast
Step 3 Long‐acting beta agonist +/– increasing dose inhaled steroid (to 800 μg) Long‐acting beta agonist +/– increasing dose inhaled steroid (to 400 μg) Combine options from Step 2
Step 4 Increase inhaled steroid dose (up to 2000 μg) +/– add further drug, e.g. leukotriene antagonist, beta agonist tablet or theophylline Increase inhaled steroid to 800 μg
Step 5 Daily steroid tablet Daily steroid tablet

Asthma in Children

Treatment principles are the same as those for adults (Table 23.2). Beware vital observation parameters are different in children:

  1. 2–5 years of age:
    • Tachycardia = >140 bpm
    • Tachypnoea = >40 respirations/minute
    • Prednisolone dose = 20 mg (in hospital)
  2. >5 years of age:
    • Tachycardia = >25 bpm
    • Tachypnoea = >30 respirations per minute
    • Prednisolone dose = 30–40 mg (in hospital)

Table 23.2 Treatment for a paediatric asthma attack (taken from British Thoracic Society, 2008 (revised 2012)).

Oxygen Via tight fitting facemask
Bronchodilator
  • Inhaler or spacer device.
  • Two puffs repeated after two minutes if no improvement.
  • Increase dose by two puffs on each subsequent dose, i.e. 2 puffs → 2 min → 4 puffs → 2 min → 6 puffs… (max 10 puffs).
  • Spacer devices can be fitted with face masks for infants.
  • Advice from the emergency services should be sought regarding nebuliser therapy if available.
Steroids
  • With expert (in hospital) advice: 20 mg prednisolone for 2–5 year of age; 30–40 mg for children over 5 years of age.
  • Patients already receiving maintenance doses of steroid should be given an additional 2 mg/kg of steroid up to 60 mg.

Other Causes of Respiratory Distress

We have focused on asthma as it represents the most common condition likely to be encountered in the scenario of acute shortness of breath. The management also encompasses a reasonable approach to almost any case of shortness of breath including undiagnosed respiratory disease.

Chronic Obstructive Pulmonary Disease

Chronic obstructive pulmonary disease (COPD) affects 3 million people in the UK. It warrants special mention as people often have a reluctance to initiate oxygen therapy. The World Health Organization definition of COPD is ‘a lung disease characterized by chronic obstruction of lung airflow that interferes with normal breathing and is not fully reversible’. This is based upon the physiological response to chronic hypercapnia seen in COPD. This leads to respiratory drive being influenced by oxygenation levels (as opposed to levels of CO2). The fear is that high flow oxygen therapy which raises blood oxygen saturation will in turn lower the respiratory drive. This is a proven physiological response and trials have shown that ‘overventilated’ patients are more likely to become acidotic. Current research suggests that in the absence of blood gas analysis, COPD patients should be provided with oxygen to aim for saturations between 90 and 92% (Resuscitation Council (UK), 2012). The aim is to ensure adequate but safe oxygenation. In the primary care setting, these guidelines provide the safest course of action.

Other patients with a risk of CO2 retention include those with chronic severe asthma, bronchiectasis, cystic fibrosis, chest wall disease and neuromuscular disease. Patients may carry alert cards with advice regarding oxygen therapy. In an emergency situation, the Resuscitation Council advise giving high flow oxygen 15 l in situations of acute shortness of breath.

Acute Shortness of Breath in a COPD Patient
  • Dental or other non‐urgent activities should be stopped and the patient placed in a comfortable seated position immediately (usually upright) with prompt assessment (ABCDE approach).
  • Check airway is clear.
  • Administer oxygen with pulse oximetry: if possible aim for oxygen saturation of 90–92%.
  • Consider two puffs of short‐acting bronchodilator beta‐2 agonists.
  • Monitor conscious level using AVPU.
  • Consider referral to the local emergency department.
  • Continue treatment whilst awaiting assistance or transfer.

Hyperventilation Syndrome

Hyperventilation syndrome (HVS) is a condition where shortness of breath is perceived in response to emotional or physical stress with worsening symptoms perpetuated by this initial symptom. Signs include:

  • Fast breathing.
  • Dizziness.
  • Feeling faint.
  • Blurred vision.
  • Tingling.
  • Muscle stiffness.

This leads to a vicious cycle which can be incredibly distressing for patient and practitioner. A history of such events as well as panic attacks may be present. This condition may present with concurrent symptoms of chest pain, paraesthesia or tingling characteristically described as perioral in nature, blurring of vision and several other non‐specific symptoms. If there is no history of true respiratory disease and absence of clinical signs, e.g. wheeze, HVS may become an important differential diagnosis. During a suspected occurrence of HVS:

  • Be calm and reassure the patient.
  • Stop the cause of the anxiety.
  • Ask the patient to concentrate on slowing their breaths.
  • Take them to a quiet room to recover.
  • The classical ‘breathing into a paper bag’ treatment can be effective for hyperventilation, but is no longer recommended.

Summary

  • Shortness of breath is a common complaint.
  • Use a structured basic/advanced life‐support approach for assessment.
  • Initiate treatment if necessary.
  • Prudent use of oxygen therapy.
  • Appropriate medication if available.
  • Constant reassessment.
  • Transfer to secondary care/emergency facility under monitored supervision.

Airway Management

Prompt recognition of airway obstruction along with appropriate management is essential for all dental personal. Use the Look‐Listen‐Feel approach.

Partial airway obstruction may be clinically diagnosed by the following:

  • Inspiratory stridor.
  • Gurgling.
  • Crowing or stridor.

Complete airway obstruction in an awake patient can be identified by clinical distress and ‘see‐saw’ breathing caused by paradoxical chest and abdominal movements when attempting to breathe.

Basic Manoeuvres to Open the Airway

Head tilt and chin lift (Figure 23.4)
Place the palm of one hand on the patient’s forehead and with the fingers of the other hand under the mentum (point of the chin) lift patient’s chin gently. This manoeuvre stretches the tissues of the neck and pulls the tongue forward to open the airway.
Check airway patency to confirm success of manoeuvre (Look‐Listen‐Feel) for no more than 10 s. Look – for movement of chest and abdomen.
Listen – for airway at the mouth and nostril.
Feel – over the mouth and nostril for airflow.
Jaw thrust (Figure 23.5)
Position patient supine. This is an alternative airway manoeuvre and is recommended in patients with suspected cervical spine injury.
Stand behind patient.
Place index and other fingers behind angle of mandible bilaterally and the thumbs on the body of the mandible bilaterally.
Apply forward force to lift the mandible and with the thumbs open the mouth by rotating the mandible slightly downwards.
Check airway patency to confirm success of the manoeuvre (Look‐Listen‐Feel).
A woman sitting on a chair with head tilt and chin lift being assisted by a woman standing beside her.

Figure 23.4 Management of airway – head tilt, chin lift.

A woman sitting on a chair with jaw thrust being assisted by a woman.

Figure 23.5 Jaw thrust.

Adjuncts to Basic Airway Manoeuvres

Simple airway adjuncts may prove essential in maintaining a patent airway. Oropharyngeal (Guedel) and nasopharyngeal airways in combination with basic manoeuvres overcome upper airway obstruction at the level of soft palate and base of tongue.

Procedure for Inserting a Guedel/Oropharyngeal Airway

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  1. Guedel airways are suitable for the unconscious patient.
Use in a conscious patient may induce vomiting and laryngospasm.
  1. Choose the appropriate size (most common for adults are sizes 2, 3 and 4).
The correct size can be estimated by placing the airway against the face. It should extend from the incisors to the angle of the mandible (Figure 23.6).
Roughly estimate size by placing the airway on one side of patient’s face. The flange should coincide with the incisors and the curved flattened end with the angle of the mandible when viewing the patient from the side.
  1. Open the patient’s mouth: ensure there is no foreign material.
Suction if necessary.
  1. Always insert the Guedel airway upside down and gradually rotate it through 180° after passing beyond the hard–soft palate junction.
Initially the curve part of the airway pushes down on the tongue.
Jan 22, 2018 | Posted by in General Dentistry | Comments Off on Medical Emergencies
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