Therapeutics for medical emergencies in dental practice
- • ‘ABCDE’ algorithm
- • Medical emergencies of relevance to dentistry
- • Medical emergency medication of relevance to dentistry
- • The management of medical emergencies in dental practise
- Adrenal insufficiency
- Cardiac emergencies
- Choking & aspiration
- Epileptic seizures
- • To be able to identify the components of the ‘ABCDE’ algorithm
- • To be able to list the medical emergencies of relevance to dentistry
- • With regards to medical emergencies in dental practice be able to identify which medications are used, and how they are used for each given condition
Potentially life threatening emergencies in the practise of dentistry are thankfully relatively rare – death in general dental practice is reported only once every 758 practising years. However, non-fatal medical emergencies in general dental practice are far more common, with 1 event every 4.5 practising years. Therefore, it is crucial that dental professionals and their teams are able to identify and manage medical emergencies within their place of work.
The protocols for managing medical emergencies have been internationally agreed by the International Liaison Committee on Resuscitation (ILCOR), European Resuscitation Council (ERC) and the Resuscitation Council (UK). Underpinning the management of medical emergency is the ‘ABCDE’ approach to assessing any patient who is unwell (Table 12.1).
Table 12.1 The ‘ABCDE’ approach to assessing any patient who is unwell
|A – Airway|
|B – Breathing|
|C – Circulation|
|D – Disability|
|E – Exposure|
The underlying principles of managing medical emergencies are shown in Table 12.2.
Table 12.2 The underlying principles of managing medical emergencies
|1. Conduct a complete ‘ABCDE’ assessment and re-assess regularly|
|2. Treat life-threatening problems before moving to the next part of the assessment|
|3. Reassess to determine the success of treatment|
|4. Recognize when to call for help – call for help early|
|5. Use all members of the clinical team, ideally to be working simultaneously and in a coordinated manner|
|6. Communicate effectively – use the Situation, Background, Assessment, Recommendation (SBAR) approach|
|7. The aim of the initial treatment is to keep the patient alive until help arrives|
This chapter looks specifically at the therapeutics of managing medical emergencies in dental practice. The emergencies discussed are shown in Table 12.3.
Table 12.3 Medical emergencies in dental practice
|Choking and aspiration|
Choking and syncope don’t usually require medication management per se; however, in the interests in completeness they have been included as part of the recognized list of medical emergencies in dental practice.
The medications referred to in this chapter are shown in Table 12.4.
Table 12.4 Emergency drugs
|Adrenaline injection (Epinephrine), adrenaline 1 in 1000, (adrenaline 1 mg/mL as acid tartrate), 1-mL amps|
|Aspirin dispersible tablets 300 mg|
|Glucagon injection, glucagon (as hydrochloride), 1-unit vial (with solvent)|
|Glucose (for administration by mouth)|
|Glyceryl Trinitrate Spray (GTN), 400 micrograms/dose aerosol sublingual spray|
|Midazolam oromucosal solution, 5 mg/mL|
|Oxygen (usually a D size cylinder in dental practice)|
|Salbutamol aerosol inhalation, salbutamol 100 micrograms/metered inhalation|
Although not a medication, the automated external defibrillator (AED) is an important part of the medical emergencies kit.
Adrenaline (epinephrine) is a non-selective catecholamine agonist of all adrenergic receptors. Pertinent to anaphylaxis, adrenaline increases peripheral resistance via α1 receptor vasoconstriction and increases cardiac output through binding to β1 receptors. In addition to being a hormone released by the adrenal glands, adrenaline is also synthesized for medical use. Due to adrenaline’s potent cardiac effects it is only generally given intramuscularly in cases of anaphylaxis. Adrenaline has a rapid onset and short half-life of around 2 minutes; side-effects include: palpitations, sweating, tremor, anxiety and headache.
Glucagon is a peptide hormone released by the alpha cells of the pancreas – its role is to raise the concentration of glucose in the bloodstream – the effect being the opposite of insulin which lowers blood glucose. Glucose is stored in the liver as the polysaccharide glycogen – glucagon released by the pancreas during periods of hypoglycaemia act to convert liver glycogen stores into glucose, which are released into the bloodstream. As glucagon is unstable in solution, it is stored as a lyophilized (freeze-dried) powder that is reconstituted with water just prior to intramuscular injection.
Once injected it may take 5 to 10 minutes for glucagon to work; moreover, it requires the patient to have adequate stores of glycogen. Therefore, glucagon may be ineffective in some patients, for example anorexics or alcoholics.