The management of medical

emergencies in dental practice

Jon White

Senior Resuscitation Officer

Milton Keynes Hospital NHS Foundation Trust

Learning outcomes

Examine the incidence of serious medical

emergencies in dental practice

Highlight current guidelines and

professional responsibilities

Discuss assessment strategies and key

management points of common medical

problems

Incidence of serious medical

problems in dental practice

Rare

‘0.7 cases per dentist per year’ (Girdler, N. 1999)

Vasovagal episodes most common

Hypoglycaemia, angina, seizures, choking

and anaphylaxis less common

Myocardial infarction and cardiac arrest

extremely rare

The General Dental Council (2005)

Medical emergencies can occur at any

time

All members of staff need to know their role

in the event of a medical emergency

Members of staff need to be trained in

dealing with such an emergency

Dental teams should practice together in

simulated emergency situations

Current guidelines

Medical emergencies and resuscitation:

Standards for clinical practice and training

for Dental Practitioners and Dental Care

Professionals (Resuscitation Council (UK), 2006)

http://www.resus.org.uk/pages/MEdental.pdf

Principles

Well consulted and endorsed by the GDC

Describes the dentists responsibilities, and those of the dental team

Interesting inclusions

• ABCDE

• Simplified range of drugs with nothing IV

• Intranasal/buccal Midazolam

• Automated External Defibrillators (AED’s)

Compliance. You will need…

Regular training(for all staff)

Appropriate equipment(checked regularly)

A plan(who does what)

Basic principles of managing an

emergency

Think about safety at all times

Assess logically and efficiently and reassess

regularly

Deal with problems as you find them with

simple interventions

Ensure that appropriate help is called

Use ABCDE to gather information, structure

handovers and as a documentation template

Assessment

Head to toe examinationExposure

AVPU? Blood sugarDisability

Pulse, perfusion, colourCirculation

Rate, effort, noise, colourBreathing

Clear? Open?Airway

ABCDE assessment

Breathing

Circulation

Disability

Talking = ok

AirwayNot talking = not ok Open the airway

Breathing rate / min

Work of breathing and noises?

Heart rate / min

Blood pressure and/or capillary refill

Level of consciousness (AVPU)

Blood sugar

Exposure Head to toe examination

Give

O2

Normal values (adults)

Breathing rate: 12 – 20 / minute

Heart rate: 60 – 100 / minute

Blood pressure > 90 mm hg (systolic)

Capillary refill < 2 seconds

Blood sugar > 4 mmols

Level of

consciousness A&V P&U ×

Medical emergencies

Common conditions

Asthma

Anaphylaxis

Chest pain

Seizures

Hypoglycaemia

Syncope

History

Severity

ABCDE

Management

Asthma – History?

Recent or current cough or cold

Recent or current oral steroids

Admission to hospital in the last year

Admission to Intensive Care Unit

Asthma - Severity

Acute severe asthma

• Unable to complete sentences in one breath

• Respiratory rate > 25

• Heart rate > 110

Life-threatening asthma

• Cyanosis or respiratory rate < 8

• Heart rate < 50

• Exhaustion, confusion or ↓LOC

Asthma - Assessment

ABCDE?

Asthma - Management

Position patient appropriately

Administer high flow Oxygen (10 litres/min)

Administer inhaled Salbutamol, ideally

using a ‘spacer’

Call an ambulance if the patient does not

respond rapidly to treatment

COPD?

Anaphylaxis – History?

Known allergies

Previous reactions to LA, antibiotics or

latex

Anaphylaxis - Severity

New ABC problems need treatment with IM

Adrenaline

• Facial swelling, stridor, hoarse voice

• Increased shortness of breath or wheeze

• ↑HR and ↓BP (or signs of poor perfusion)

Mild reactions?

Anaphylaxis - Assessment

ABCDE?

Anaphylaxis - Management

Position patient appropriately

Administer high flow Oxygen (10 litres/min)

Administer intramuscular Adrenaline 0.5

mg (1:1000) if new A, B or C problem

Call an ambulance

Consider inhaled Salbutamol if wheeze

present

Chest pain – History?

Individuals with exert ional (stable) angina

may experience chest pain as a result of

dental treatment

Patients with a recent history of admission

to hospital with angina not associated with

exertion or stress (unstable) should be

referred for dental treatment

Chest pain - Severity

Any pain in the chest should be presumed

to be cardiac in origin

Stable angina that responds to GTN should

probably not cause concern

An ambulance should be called to those

patients with atypical pain or pain that

starts without a trigger

Chest pain - Assessment

ABCDE?

Chest pain - Management

Position patient appropriately

Administer high flow Oxygen (10 litres/min)

Call an ambulance

Administer sublingual Glyceryl trinitrate (2

tablets or 2 puffs)

Administer Aspirin 300 mg orally, crushed

or chewed

Seizures – History?

Form an opinion about how well controlled the patients seizures are

Any change in seizure pattern or a change in medication are significant factors

Be prepared

• What is their seizure like?

• Are there any precipitating factors?

• Do they get an aura?

Seizures - Severity

An ambulance should be called if…

Atypical seizure or status epilepticus

First seizure

Incomplete recovery after a seizure

Injury during a seizure

Seizures - Assessment

ABCDE?

Seizures - Management

Protect the patient from harm during a seizure

Administer high flow Oxygen (10 litres/min)

Do not attempt to insert anything in the patients mouth during the seizure

If the seizure last more than 5 minutes medication will be necessary

Buccal or intranasal Midazolam 10 mg?

Hypoglycaemia – History?

Insulin dependent (Type 1) diabetics are more likely to have hypoglycaemic episodes

Patients that describe poor control of their condition or a lack of awareness are the highest risk group

Non diabetic individuals can be hypoglycaemic!

Hypoglycaemia - Severity

Hypoglycaemic individuals generally

respond promptly to glucose and/or IM

Glucagon

An ambulance should be called to those

individuals that do not respond to these

treatments

Hypoglycaemia - Assessment

ABCDE?

Hypoglycaemia - Management

Conscious and cooperative?

Give Glucose orally

Uncooperative and/or ↓LOC?

Manage patient safely

Administer Glucose gel buccaly and/or IM

Glucagon 1 mg

Observe for response to treatment

Syncope – History?

Some individuals will report regular or

frequent ‘faints’

Have they been investigated?

Syncope – Is it?

Probably Syncope Possibly not Syncope

No clear precipitating

factorOther symptom/signs

Sudden loss of

consciousness

More gradual reduction

in level of consciousness

Prompt recoverySlow or no recovery or

deteriorates further

Syncope - Assessment

ABCDE?

Syncope - Management

Position patient appropriately

Administer high flow Oxygen (10 litres/min)

Observe closely

Questions?

Summary

Be prepared

Be calm

Be safe