Kathleen Fan, Syedda Abbas, Shariff Anwar, Nikolas Fanaras, Leandros Vassiliou, Rahul Jayaram, Andrew Ross and Suranjana Lahiri
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).
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 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
|Choking (Figures 23.2 and 23.3)||
|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.|
|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||
|D – Disability|
|Refers generally to the conscious state of the patient and what may be affecting it.
Look and Listen
|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.|
- 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 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)):
- Moderate exacerbation:
- Increasing symptoms.
- Peak expiratory flow (PEF) 50–75% best/predicted.
- No severe attack symptoms.
- Acute severe attack:
- Inability to complete sentences.
- Respiratory rate >25/min.
- Tachycardia >110.
- PEF 33–50% best/predicted.
- Life‐threatening attack:
- Severe asthma symptoms +:–.
- Bradycardia (heart rate <50 bpm).
- Exhaustion and conscious level drop.
- Oxygen saturations <92%.
- Silent chest.
- PEF <33% best/predicted.
- Poor respiratory effort.
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.
|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.||
|Beta‐agonists (e.g. salbutamol) are often the staple of obstructive airway disease. Their actions on receptors are believed to cause:||
|The mode of bronchodilator delivery will be determined by the patient.||
|Escalation of treatment would include:||
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|
(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:
- 2–5 years of age:
- Tachycardia = >140 bpm
- Tachypnoea = >40 respirations/minute
- Prednisolone dose = 20 mg (in hospital)
- >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|
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 (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.
- Feeling faint.
- Blurred vision.
- 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.
- 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.
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.
- 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).|
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
||Use in a conscious patient may induce vomiting and laryngospasm.|
||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.|
||Suction if necessary.|
||Initially the curve part of the airway pushes down on the tongue.|