Walsall Healthcare

NHS Trust

MEDICAL EMERGENCIES IN THE DENTAL PRACTICE

MEDICAL EMERGENCY Anaphylaxis SIGNS & SYMPTOMS Signs & symptoms may include: Sudden onset Urticaria Angioedema Flushing & pallor Respiratory distress Stridor, wheeze &/or hoarse voice Hypotension Tachycardia TREATMENT ABCDE approach; call 999 Lie flat, elevate legs (if breathing not impaired) Administer oxygen 15 litres/min Administer adrenaline 500 micrograms IM (0.5ml of 1:1000 solution) If necessary, repeat adrenaline at 5 minute intervals according to blood pressure, pulse respiratory function Paediatric doses for adrenaline: < 6 years - 150 micrograms (0.15mls of 1:1000) 6-12 years - 300 micrograms (0.3mls of 1:1000) > 12 years -500 micrograms (0.5mls of 1:1000) ABCDE Approach Sit upright Administer 2 puffs (100 micrograms/puff) of short acting bronchodilator inhaler e.g. salbutamol; repeat doses may be necessary If patient unable to effectively use inhaler, administer additional doses through spacer device Call 999 if no response or if severe or life threatening While awaiting ambulance: administer oxygen 15 litres per minute; up to 10 activations of salbutamol inhaler using a spacer device should also given (repeated every 10 minutes if necessary) Reassure patient Call 999 ABCDE approach Comfortable position Administer GTN e.g. 2 activations of GTN spray If no known allergy, administer aspirin 300mg orally (crushed or chewed) Cyanosis (blue lips) or if deterioration in level of consciousness: administer oxygen 15 litres/min NB If history of angina, encourage patient to take own medication e.g. GTN, & rest; where symptoms are mild and respond rapidly with medication, calling 999 usually not necessary ABCDE approach Ensure safe environment: prevent injury, do not put anything into mouth, do not restrain Administer oxygen 15 litres/min Once jerking movements cease: recovery position Check for slow heart rate (can cause seizure) Check blood glucose (hypoglycaemia can cause seizure): if < 3mmols/litre, treat for hypoglycaemia (see below) Following seizure, place in recovery position Prolonged seizures (lasting 5 mins or longer) or seizures recurring in quick succession: call 999 & administer midazolam 10mg via buccal route Refer to hospital if status epilepticus, high risk of recurrence, first episode, difficulty monitoring patients condition (NICE) Paediatric doses of buccal midazolam: 1-5 years - 5mg 5-10 years - 7.5mg > 10 years 10mg Measure blood glucose to confirm diagnosis Call 999 if any difficulty experienced or patient does not respond Co-operative, conscious & able to swallow safely: Offer 10-20g glucose e.g. orange juice, non-diet fizzy drink, 4 x glucose tablets or gel Impaired consciousness & unable to swallow safely: Administer buccal glucose gel &/or glucagon 1mg IM Once consciousness returns, offer oral glucose Paediatric dose of glucagon < 8 years of age or < 25kg: 0.5mg ABCDE approach Call 999 Ensure airway patent may be necessary to place in recovery position Administer oxygen 15 litres/min Do not offer anything to eat or drink

Asthma

Breathlessness & expiratory wheeze Severe: inability to complete sentences in one breath, RR>25/min, pulse>110/min Life threatening: cyanosis or RR<8/min, pulse < 50/min, exhaustion, confusion, decreased level of consciousness

Cardiac emergencies

Heart attack (myocardial infarction) Severe, crushing central chest pain (may radiate to neck, jaw shoulders, left arm & back) Pallor, sweating Nausea/vomiting Breathlessness

Epileptic seizure

Sudden collapse & loss of consciousness Tonic phase (approx 30 secs) Rigidity & cyanosis Clonic phase (few mins) Jerking movements of limbs, tongue may be bitten; frothing at mouth & incontinence may occur Following seizure Patient flaccid and remains unconscious (variable period); gradually regains consciousness, may be confused

Hypoglycaemia

Shaking/trembling Slurred speech Vagueness Sweating Double vision Confusion Unconsciousness Children may just appear lethargic

Stroke

Syncope

Facial weakness: smile? mouth or an eye lid drooped? Arm weakness: raise both arms? Speech problems: speak clearly and understand what is being said? Test all three symptoms (FAST: Stroke Association) Feels faint/dizzy/light headed Collapse & loss of consciousness Pallor, sweating, slow pulse, low BP Nausea/vomiting

Lie flat & elevate legs Loosen tight clothing Administer oxygen 15 litres/min If becomes unresponsive, check for signs of life

References British Medical Association & the Royal Pharmaceutical Society of Great Britain (2010) British National Formulary 56 Royal Pharmaceutical Society, London Jevon P (2009) Medical Emergencies in the Dental Practice Wiley Blackwell, Oxford Resuscitation Council UK (2011) Medical emergencies and resuscitation standards for clinical practice and training for dental practitioners and dental care professionals in general dental practice Resuscitation Council UK, London Acknowledgements Poster, designed as an aid memoir by Phil Jevon, Resuscitation Officer/Clinical Lead, Manor Hospital, Walsall, Text proof read by Mr N Rashid & Miss R Joshi, A & E Consultants and Mrs S Church, Consultant Orthodontist, Walsall Healthcare NHS Trust, Manor Hospital Walsall, UK
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