AUSTRALIAN DENTAL ASSOCIATION INC. GUIDELINES FOR GOOD PRACTICE ON EMERGENCIES IN DENTAL PRACTICE INTRODUCTION: Dentists and their staff should be prepared for emergency situations which will occur at any time in their practices. These emergencies range from the minor such as the common faint [vaso-vagal syndrome] and hyperventilation, to the life-threatening such as cardiac arrest or anaphylaxis. An Australian study [Chapman, 1997] showed that about one in seven dentists surveyed had had to resuscitate a patient, whilst an American study covering a ten year period revealed that over 30,000 emergencies arose from a surveyed population of some 4,000 dentists [Malamed, 1992.] If it is possible to over-prepare, however, and it is the aim of this code to be as simple as practicable since over preparation without appropriate experience will be counterproductive and even dangerous [eg. excessive drugs and equipment.] FIVE STEPS IN THE PREPARATION FOR EMERGENCIES. Step 1. Medical History. Step 2. Assessment of patient/Recognition of cause of emergency Step 3. Resuscitation - knowledge, training and practice. Step 4. Emergency Drugs and Devices. Step 5. Calling for Medical Assistance.

-2- Step 1. MEDICAL HISTORY. This aspect of practice is constantly covered and, therefore, will not be laboured but should include:- a. Date of birth. b. Physician's name, telephone number and address. c. Past and present serious illnesses.

Prompts: Heart disease [Ischaemic heart disease/congestive heart failure] Blood pressure Stroke Rheumatic heart disease Diabetes Asthma

d. Blood transfusion history

Prompt: If positive: <Are you being treated by a doctor at present?' e. Allergies to drugs, medicines, antiseptics.

Prompts: Penicillin Local anaesthetic Antiseptics Latex.

f. Present Medication.

Prompt: <What medicine, pills. tablets or drugs are you taking or have you taken recently [in the last six months]?

Where there is any doubt regarding the patient's medical status, the dentist should consult the patient's medical practitioner. STEP 2. ASSESSMENT OF PATIENT. The following conditions are recognised as the predominant causes of medical emergencies in dental surgeries. The first five are stress related. ie. initiated or aggravated by emotional stress and stress minimisation techniques can assist in the prevention of such conditions. The conditions will exhibit a range of clinical features and the dentist should be vigilant regarding the patient's medical history and the circumstances which may have provoked the condition.

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CONDITION

CLINICAL FEATURES

TREATMENT/ RESPONSE

1

Vasovagal syncope [fainting] approximately 40%.

Faintness, weakness, pallor, sweaty skin, lowered pulse rate, hypotension.

Lie horizontally, elevate feet, oxygen, monitor vital signs.

2

Hyperventilation approx.30% [frequently confused with syncope].

Dyspnoea, rapid breathing, faintness, paraesthesia of extremities, palpitations.

Encourage slower breathing, rebreath expired air with a paper bag.

3

Asthma [Medical History]

Dyspnoea, cyanosis, audible wheezing, cyanosis.

Reassure, use up to 4 metered doses of aerosol bronchodilator.

4

Angina Pectoris [Medical History]

Moderate to crushing central chest pain, radiating to left arm, neck or mandible.

Stop treatment, place one glyceryl trinitrate tablet 0.6 mg under tongue or spray under tongue. Repeat dose in 5 minutes after first checking BP and again after another 5 minutes if pain persists. If no improvement after 15 minutes, treat as acute myocardial infarction.

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Acute myocardial infarction. [Medical History. eg. angina pectoris, acute myocardial infarction, hypertension, diabetes.]

Chest pain similar to angina but unrelieved by up to 3 glyceryl trinitrate tablets over 10 minutes. Suspect in anginal patient who says pain is much worse than usual, or if this is first ever episode of chest pain.

Call 000. Monitor vital signs. 100% oxygen. Dissolved aspirin tablet and one glyceryl trinitrate dose stat and one repeat in 5 minutes after check of BP.

6

Cardiac arrest. [Medical history especially angina and acute myocardial infarction.]

Sudden unconsciousness, no breathing, no pulse.

[Irreversible brain damage in 3-5 minutes] Call 000 immediately. Initiate cardio pulmonary resuscitation, early defibrillation, oxygen.

7

Epilepsy [Grand Mal] [Inquire as to control of condition, medication, last episode.]

Sudden unconsciousness, temporary aspnoea and cyanosis in tonic phase, involuntary movement of limbs in clonic phase.

Place in lateral position, protect from injury, monitor vital signs, oxygen, medical assistance.

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Toxic effects from LA [rare].

1. Adrenaline toxicity - restlessness, throbbing headache, pallor, rapid full pulse, palpitations. 2. LA base toxicity - first CNS stimulation then depression with convulsions.

Basically supportive - effects should terminate rapidly.

9

Hypoglycaemia [History of insulin dependent diabetes.]

Slurred speech, altered behaviour, sweating, rapid pulse, apprehension, then loss of consciousness.

Give orange juice, glucose drink or sugar lumps at first sign which will rapidly terminate event ie. loss of consciousness should never occur. If loss of consciousness occurs, will need parenteral therapy [glucose or glucagon.]

10

Acute airway obstruction [choking].

Sudden aspnoea or dyspnoea cyanosis, violent coughing spasms, inability to catch breath.

Try to remove cause - 5 back blows with patient leaning forward. If unable to remove, administer oxygen, arrange transfer to hospital for bronchoscopy.

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Severe Allergic reaction. [Anaphylaxis]. NB. History of allergies.

Asthma like symptoms. [sneezing and dyspnoea] circulatory collapse, cardiac arrest, following drug administration.

Call 000. Always check that respiratory distress not due to other causes. Adrenalin 1:1000 IM [1/2 ml] as injection or epipen. May need to repeat dose after 5 minutes. 100% oxygen. CPR if cardiac arrest occurs.

COLLAPSE Check response, shake and shout

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STEP 3. RESUSCITATION - KNOWLEDGE, TRAINING AND PRACTICE. Further annual refamiliarization courses are recommended to main competence in basic life support [BLS]. All dentists should be competent in BLS resuscitation. That is, they should be able to assess breathing and circulation and to carry out effective expired air resuscitation [EAR] and Cardio-pulmonary resuscitation [CPR] if required. They should also encourage their staff to attend resuscitation courses and run practice drills with surgery staff. A wall poster can assist in retention of learnt techniques. When an emergency is immediately life threatening such as complete laryngeal obstruction, cardiac arrest associated with acute myocardial infarction, or bronchospasm associated with anaphylaxis, there is no time for delay and an immediate diagnosis must be made and definitive treatment initiated. The Australian Resuscitation Council recommends the DRABC basic sequential steps for all emergency situations. These steps are to ensure an adequate delivery of oxygenated blood to the brain prior to the delivery of definitive care – D = Check for danger. R = Check if the patient is responding. A = Check the airway for obstruction. B = Assess breathing. C = Assess circulation. FLOW CHART FOR ABC OF RESUSCITATION.

CONSCIOUS Make comfortable Observe. Airway

Breathing Circulation

UNCONSCIOUS Turn on side Face slightly downward Clear airway Head tilt Jaw support/jaw thrust Check for breathing

BREATHING Leave on side in lateral position Observe. Airway

Breathing Circulation

NOT BREATHING Turn on back 5 full breaths [10 seconds] EAR Check carotid pulse

PULSE PRESENT Continue EAR Check pulse and breathing after 1 minute and then at least every 2 minutes.

PULSE ABSENT

CPR [EAR and ECC] Check pulse and breathing after 1 minute and then at least every 2 minutes

EAR Expired air resuscitation ECC External cardiac compression CPR Cardiopulmonary resuscitation ie. EAR and ECC

-5- STEP 4. EMERGENCY DRUGS AND DEVICES. The administration of emergency drugs is always secondary to providing life support during an emergency. There are no mandated lists of emergency drugs and equipment kits except in the practices that undertake intramuscular or intravenous sedation or general anaesthesia. Dentists who undertake the administration of oral conscious sedation on children or adults should have adequate training to deal with any side effects. It is recommended, though not mandated, that a general practice retains on its premises the following : ! Oxygen ! Oral glucose ! Adrenaline 1:1000 ! Clyecryl trinitrate spray or tablets. OXYGEN. All surgeries should have an oxygen source which is easily transported to the patient. The simplest and safest way of administering oxygen to a non-breathing patient is via a pocket mask with a nozzle to which a low pressure oxygen line is connected. At a flow rate of 10L/minute this provides about 50% oxygen in the ventilated air. The mask should have an adjustable head strap. Oxygen powered resuscitators are considered part of advanced life support [ALS] because of the risk of gaseous distension of the stomach resulting in regurgitation, therefore, are not recommended. It is now considered that these resuscitators require two operators. ORAL GLUCOSE. For insulin dependant patients who are exhibiting signs of hypoglycaemia, administration of orange juice, glucose or sucrose drinks or sweets in small amounts [50-100 ml] every five minutes, will rapidly raise the blood sugar level and reverse the situation. ADRENALIN 1:1000. When a severe anaphylactic allergic response is diagnosed, an injection of 0.3 - 0.5 mg [0.3 ml - 0.5 ml of 1:1000 solution] on to the tongue, floor of the mouth or other muscle is required. Adrenaline is available as a 1 ml 1:1000 solution in a pre-loaded syringe. Two such pre-loaded syringes should be kept, as the injection may need to be repeated. Pressure adrenaline kits [epipens] are available in adult and child doses. GLYCERYL TRINITRATE TABLETS OR SPRAY. Patients with a history of angina usually have their tablets with them and administer their usual dose sublingually. However, it is recommended that the dentist's emergency kit contain glyceryl trinitrate spray [which has a much longer shelf life than tablets] in case the patient does not have his/her glyceryl trinitrate [GTN] tablets. STEP 5. CALLING FOR MEDICAL ASSISTANCE. Apart from the use of 000, it is appropriate for a dentist to make established links with his nearest medical practitioner or facility. Therefore, these should be displayed in a prominent place. Other than administering oxygen, it must be stressed that no drugs should be administered if a dentist is not adequately trained and confident of the diagnosis.

-6- REFERENCES. 1. Chapman, PJ. A questionnaire survey of dentists regarding knowledge and perceived competence in

resuscitation and occurrence of resuscitation emergencies. Australian Dental Journal 19915; 40 (2): 98-103

2. Chapman, PJ. Notes for Dental Students. University of Queensland. 3. Chapman, PJ. Medical emergencies in dental practice and choice of emergency drugs and equipment:

A survey of Australian dentists. Unpublished. 4. Malamed, GF. Managing Medical Emergencies. Journal of American Dental Association 1993. 124:

40-53. 5. McCarthy, FM. Emergency drugs and devices - less is more. Canadian Dental Association Journal

1993. February 19-25. 6. NHMRC. Emergencies in Dental Practice. Australian Government Publishing Service, Canberra,

1981. 7. NHMRC. Emergencies in Dental Practice. Unpublished, 1993. 8. Herman, WW and Konzelman, JL. Angina: an update for dentistry. Journal of the American Dental

Association 1996. 127: 98-104. 9. Resuscitation in the Electrical Industry. QEC. 1990.

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GUIDELINES FOR GOOD PRACTICE ON EMERGENCIES IN DENTAL PRACTICE Prepared by Dental Practice Committee, February 13, 1998 Adopted as a Code of Practice by Federal Council, April 15/16, 1999 Amended by Federal Council, November 11/12, 1999 Adopted as Guidelines for Good Practice by Federal Council, November 11/12, 1999 Amended by Special Purpose Committee on Therapeutics & Drugs, June 2005