The management of medical emergencies in dental practice Emergencies in Dental Practic… ·...

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  • 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


  • Incidence of serious medical

    problems in dental practice


    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


    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)

  • Principles

    Well consulted and endorsed by the GDC

    Describes the dentists responsibilities, and those of the dental team

    Interesting inclusions


    Simplified range of drugs with nothing IV

    Intranasal/buccal Midazolam

    Automated External Defibrillators (AEDs)

  • Compliance. You will need

    Regular training(for all staff)

    Appropriate equipment(checked regularly)

    A plan(who does what)

  • Basic principles of managing an


    Think about safety at all times

    Assess logically and efficiently and reassess


    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




    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



  • 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



    Chest pain








  • 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


  • 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


  • Anaphylaxis History?

    Known allergies

    Previous reactions to LA, antibiotics or


  • Anaphylaxis - Severity

    New ABC problems need treatment with IM


    Facial swelling, stridor, hoarse voice

    Increased shortness of breath or wheeze

    HR and BP (or signs of poor perfusion)

    Mild reactions?

  • Anaphylaxis - Assessment


  • 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


  • 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


  • 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


  • 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


    An ambulance should be called to those

    individuals that do not respond to these


  • Hypoglycaemia - Assessment


  • 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


    More gradual reduction

    in level of consciousness

    Prompt recoverySlow or no recovery or

    deteriorates further

  • Syncope - Assessment


  • Syncope - Management

    Position patient appropriately

    Administer high flow Oxygen (10 litres/min)

    Observe closely

  • Questions?

  • Summary

    Be prepared

    Be calm

    Be safe