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Medical Emergencies In The Dental Clinic

Setting Priorities: Patient Safety Must Come First

An emergency is a medical condition demanding immediate treatment. Emergencies do occur in dental clinics. Every dentist should have the basic knowledge to recognise, assess and manage a potentially life-threatening situation until the patient can be transported to a medical facility. Successful patient management relies on understanding the pathophysiologic processes and how to correct them. Keep in mind that some emergencies end in disaster even in hospitals where there is optimal management. People have heart attacks every day — they may just happen to be in your office at the time. You need to know what to do in order to give the patient the best chance of recovery.

Preparation For Emergencies

Prevention

Comprehensive medical history must be recorded for all the patients and must be updated regularly. An assessment should be made to judge patients with severe medical conditions should be undertaken as to their suitability for undertaking dental treatment. Patients with severe or unstable medical conditions should be referred for treatment in dental hospital.

Training

The staff in the clinic should have appropriate training. A team approach to resolve of medical emergencies should be inculcated. Protocols should be in place so that staff members know their role in managing emergency situations. Having a handy Emergency Drug Kit is essential; however preparedness to follow the correct emergency protocol and correct administration of the drugs is paramount. To be able to be effective; get trained conduct mock drills and practice regularly. Know the basics of Recording and Evaluation Vital statics, ABC of resuscitation, how to administer oxygen, intramuscular and where appropriat intravenous delivery of medicine are required. Training and certificate programmes for the same must be availed.

Equipment and Drugs

Drugs and emergancy equipment must readily available and up-to-date. They should be stored to facilitate easy identification. The equipment must be checked frequently to make sure it is operational.

The following equipment must be carried and be readily available in dental practices:

  • Oxygen cylinder and regulator suitable for delivering high flow of oxygen.
  • Syringes and needles for drawing and administering drugs.
  • Bag mask device with oxygen reservoir.
  • Basic airway adjuncts (oro-pharyngeal and naso-pharyngeal airways).
  • Equipment for recording blood pressure.
  • Spacer device to deliver Salbutamol.
Drugs Indication Initial Adult Dose
1. Oxygen Almost any medical emergency 100%inhalation
2. Epinephrine Anaphylaxis. Aasthma unresponsive to albuterol/ salbutamol. Cardiac arrest. 0.1 mg IV or 0.3-0.5mg IM. 0.1 mg IV or 0.3-0.5mg IM. 1.0 mg IV.
3. Nitroglycerin Angina pain 0.3-0.4mg sublingual
4. Antihistamine (dephenhydramine or chorpheniramine) Allergic relations 25-50mg IV, IM. 10-20mg IV, IM
5. Albuterol/salbutamol Asthmatic bronchospasm 2sprays: inhalation
6. Aspirin Myocardial infraction 160-325 mg.
1. Glucagon hypoglycemia in unconscious patient 1 mg IV or IM.
2. Atropine clinically significant bradycardia 0.5 mg IV or IM.
3. Ephedrine clinically significant hypotension 5 mg IV or 10-25 mg IM.
4. Hydrocortisone adrenal insufficiency recurrent anaphylaxis 100 mg IV or IM. 100 mg IV or IM.
5. Morphine and nitrous oxide angina-like pain unresponsive to nitroglycerin tritate 2 mg IV, 5 mg IM ~35%, inhalation.
6. Lorazepam or Miodazolam status epilepticus 4 mg IM or IV. 5 mg IM or IV.
7. Flumazenil benzodiazepine overdose 0.1 mg IV.
Oxygen

Oxygen is indicated for every emergency except hyper-ventilation. This should be done with a clear full face mask for the spontaneously breathing patient and a bag-valve-mask device for the apnoeic patient. It should not be withheld for the patient with chronic obstructive lung disease, even though they may be dependent on low oxygen levels to breathe if they are chronic carbon dioxide retainers. Short term administration of oxygen to get them through the emergency should not depress their drive to breathe.

Oxygen should be available in a portable source, ideally in an “E”-size cylinder which holds over 600 liters. This permits enough oxygen to be available for the patient until transfer to a hospital. If the patient is conscious or unconscious yet spontaneously breathing, oxygen should be delivered by a full face mask, with a flow rate of 6 to 10 liters per minute is appropriate for most adults. If the patient is unconscious and apneic, it should be delivered by a bag-valve-mask device where a flow rate of 10 to 15 liters per minute.A positive pressure device may be used in adults, provided that the flow rate does not exceed 35 liters per minute.

Epinephrine

Epinephrine is the drug of choice for the emergency treatment of anaphylaxis and asthma which does not respond to its drug of first choice, albuterol or salbutamol. Epinephrine is also indicated for cardiac arrest, but in the dental office setting, it may not be given since intravenous access may not be available. Its administration intramuscularly is not as likely to be very effective in case of emergency, where adequate oxygenation and early defibrillation is most important for the cardiac arrest dysrhythmias with the relatively best prognoses, namely ventricular fibrillation or pulse-less ventricular tachycardia.

As a drug, epinephrine has a very rapid onset and short duration of action, usually 5 to 10 minutes when given intravenously. For emergency purposes, epinephrine is available in two formulations. It is prepared as 1: 1,000, which equals 1 mg per ml, for intramuscular, including intralingual injections. More than one ampule or pre-filled syringe should be present as multiple administrations may be necessary. It is also available as 1: 10,000, which equals 1 mg per 10 mL for intravenous injection. Autoinjector systems are also present for intramuscular use (such as the EpiPen) which provides one dose of 0.3 mg as 0.3 mL of 1: 1,000, or the pediatric formulation which is 1 dose of 0.15 mg as 0.3 mL of 1: 2,000.

Initial doses for the management of anaphylaxis are 0.3 to 0.5 mg intramuscularly or 0.1 mg intravenously. These doses should be repeated as necessary until resolution of the problem. Similar doses should be considered in asthmatic bronchospasm which is unresponsive to a beta-2 agonist, such as albuterol or salbutamol. The dose in cardiac arrest is 1 mg intravenously.

Epinephrine is clearly a highly beneficial drug in these emergencies. Concurrently, however, it can be a drug with a high risk if given to a patient with ischemic heart disease. Nevertheless, it is the primary drug needed to reverse the life-threatening signs and symptoms of anaphylaxis or persistent asthmatic bronchospasm.

Nitroglycerin

This drug is indicated for acute angina or myocardial infarction. It is characterised by a rapid onset of action. For emergency purposes it is available as sublingual tablets or a sublingual spray. One important point to be aware of is that the tablets have a short shelf-life of approximately 3 months once the bottle has been opened and the tablets exposed to air or light. The spray has the advantage of having a shelf-life which corresponds to that listed on the bottle. Therefore, if a patient uses his/her own nitroglycerin, there is a possibility of the drug being inactive. This supports the need for the dentist to always have a fresh supply available. With signs of angina pectoris, one tablet or spray (0.3 or 0.4 mg) should be administered sublingually. Pain should occur within minutes. If necessary, this dose can be repeated twice more at 5-minute intervals. Systolic blood pressures below 90 mmHg contraindicate the use of this drug.

Injectable Antihistamine

An antihistamine is indicated for the management of allergic reactions. Whereas mild non-life threatening allergic reactions may be managed by oral administration, life-threatening reactions necessitate parenteral administration.

Two injectable agents may be considered, either diphenhydramine or chlorpheniramine. They may be administered as part of the management of anaphylaxis or as the sole management of less severe allergic reactions, particularly those with primarily dermatologic signs and symptoms such as urticaria. Recommended doses for adults are 25 to 50 mg of diphenhydramine or 10 to 20 mg of chlorpheniramine.

Albuterol (Salbutamol)

A selective beta-2 agonist such as albuterol (salbutamol) is the first choice for management of bronchospasm. When administered by means of an inhaler, it provides selective bronchodilation with minimal systemic cardiovascular effects. It has a peak effect in 30 to 60 minutes, with a duration of effect of 4 to 6 hours. Adult dose is 2 sprays, to be repeated as necessary. Pediatric dose is 1 spray, repeated as necessary.

Aspirin

Aspirin (acetylsalicylic acid) is one of the more newly recognised life-saving drugs, as it has been shown to reduce overall mortality from acute myocardial infarction.

The purpose of its administration during an acute myocardial infarction is to prevent the progression from cardiac ischemia to injury to infarction. There is a brief period of time during a myocardial infarction where aspirin can show this benefit. For emergency use there are relatively few contraindications. These would include known hypersensitivity to aspirin, severe asthma or history of significant gastric bleeding. The lowest effective dose is not known with certainty, but a minimum of 162 mg should be given immediately to any patient with pain suggestive of acute myocardial infarction.

Oral Carbohydrate

An oral carbohydrate source, such as fruit juice or non-diet soft-drink, should be readily available. Whereas this is not a drug and perhaps should not be included in this list, it is considered essential in the management of hypoglycemia in conscious patients.

Management Of Medical Emergencies

Generic Response To The Unconsious Patient

Initial assessment and management of an unconscious/collapsed patient follows a similar pattern despite the diversity of possible causes. Unconsciousness can be caused by deterioration of medical conditions, drug administration or trauma. However the most common causes of loss of consciousness are

Vasovagal Attack Often associated with anxiety. Usually, though not always, some premonitory symptoms of faintness before losing consciousness are cold clammy skin, pallor, initially bradycardia and low pulse , followed by tachycardia and full pulse. Rapidly recovering in supine position or slightly head down(maximum recommended inclination 10 degrees).
Hypoglycaemia Seen in starved patients or diabetics with relative insulin overdose caused by starvation or stress. Rapid recovery on administering oral glucose or if unconscious, glucagons followed by oral glucose on regaining consciousness.
Steroid Crisis Seen only in those taking systemic steroids as a result of stress.
Cardiac Arrest No central pulse. Usually history of angina, coronary arterial disease, hypertension or other risk factors.

Fainting (vasovagal syncope) is innocuous providing, it is recognized. It is easily the most common cause of sudden loss of consciousness, with up to 2% of patients fainting before or during dental treatment. The possibility of vasovagal syncope while under GA, and hence failure to recognize the condition and correct cerebral hypoxia is the major reason for recommending the supine position.

Predisposing factors

Pain; Anxiety; Fatigue; Relative hyperthermia; Fasting.

Signs and Symptoms
  • A feeling of dizziness and nausea: pale.
  • Cold and clammy skin.
  • Slow, thready pulse which rebounds to become rapid;
  • Loss of consciousness with collapse, if unsupported.
Differential Diagnosis

A faint may mimic far more serious conditions; most of which can be excluded by a check of patient's medical history. These include strokes, corticosteroid insufficiency, drug reactions and interactions epileptic fit heart block, hypoglycemia and MI.

Prevention

Avoid predisposing factors. Treat patients in the supine position unless specifically contraindicated (e.g. heart failure. pulmonary oedema).


Management
  • Lower the head to the level of or below the heart. Best achieved by laying the patient flat with legs slightly elevated.
  • Loosen clothing (in the presence of a witness).
  • Monitor pulse. If recovery does not occur rapidly then reconsider the diagnosis..
  • Determine the precipitant and avoid in the future.
  • If bradycardia persists with no evidence of recovery to rapid full pulse, try tiny dose of atropine (100 IJg IV). Dose may be repeated up to 600 IV.
Diagnosis and Management

For a diagnosis of cardiac arrest the patient must have:

  • No central pulse
  • Be unconscious

Examination: You place a hand on the patient’s neck to feel the carotid pulse.

Protocol/Basic Life Support
  1. Check area for danger.
  2. Assess responsiveness by shaking and shouting .
  3. Call for help.
  4. Open the airway (tilt head back and chin lift or jaw thrust).
  5. Check mouth for vomit/debris and remove with finger sweeps.
  6. Assess breathing- Listen and feel for breathing whilst observing chest movements (up to 10 seconds). If not breathing, phone for help immediately (ambulance or Emergency Helpline).
  7. Give two slow ventilations (up to 5 attempts).
  8. Assess the Carotid Pulse (up to 10 seconds). i. If the pulse is present but the patient is still not breathing; give 10 ventilations and recheck the carotid pulse every minute. ii. If no pulse is present then, perform 15 chest compressions of 4-5 cm each on the lower third of the sternum at a rate of 100 per minute, followed by two ventilations.
  9. If the pulse is restored, reassess breathing and if satisfactory then place the patient in the recovery position and administer oxygen. Otherwise, continue ventilations and compressions until help arrives.
Collapse in a patient with a history of corticosteroid use

The use of corticosteroids therapeutically suppresses the adrenal response to stress. This is more likely this is to occur in the cource of treatment and with higher the dose.

The prime aim is to prevent the occurrence of stress-induced collapse; if patients has received steroids in the past year or is on steroids at present, cover any stressful procedure, anaesthetic, infection or episode of trauma with 100 mg hydrocortisone 1M 30 min prior to elective stress.

It is a fallacy to believe that you are reducing the risk of steroid unwanted effects by trying to avoid giving prophylactic steroids.

Doubling the oral dose may work but is rather hit and miss. Calculating an 'exact' dose is unnecessarily complicated.Prescribe them with 100 mg hydro¬cortisone 1M unless you have a very valid reason to change.

Signs and Symptoms

Treat immediatly patients suffering acutely. If collapse occurs in such a patient, diagnosis is established by pallor, rapid, thin pulse with a profound and sudden drop in BP and loss of consciousness.

Management

Place in supine position. Maintain airway. Give O2. Obtain IV access up to 500 mg hydrocortisone IV immediately. Ensure help (i.e. an ambulance) is requested. Exclude other causes of collapse.

It is worth remembering that there is a 10% cross-over in allergic response between penicillins and cephalosporins. An anaphylactic reaction is not an all-or-nothing response and grades of severity are seen. Generally, the reaction starts a few minutes after a parenteral injection and not immediately.Some caution should be exercised, though, as the quicker the onset of an anaphylactic reaction the more severe it is likely to be.

While there are a multitude of drug interactions which the dental surgeon should be aware of as a prescriber. The drugs most liable to present an emergency problem to the dentist are those which we administer as LAs. Although it is possible to achieve toxic levels of lignocaine, adrenaline, prilocaine, or felypressin without intravascular injection, this generaly requires a particularly cavalier attitude to the administration of LA. Commonly, this effect is due to intravascular injection of a substantial proportion of a cartridge of LA. Confusion, peri-oral tingling, drowsiness, agitation, fits, or loss of consciousness may occur. Do not use more than 10x2.2 ml cartridges of lignocaine/adrenaline (440 mg lignocaine). In practice, you will rarely consider coming near this amount.

Symptoms

Are facial flushing, itching, numbness, cold extremities, nausea and sometimes abdominal pain.

Signs

Include wheezing, facial swelling, rash, and cold clammy skin with a thin thready pulse. Loss of consciousness may occur, with extreme pallor which progresses to cyanosis as respiratory failure develops.

Differential diagnosis

It can be difficult to distinguish anaphylaxis from acute asthma in, e.g., an asthmatic given an NSAID they are allergic to. Don't panic, just go through management for acute asthma, then start on management for anaphylaxis. Adrenaline is a bronchodilator. Angioedema is sudden in onset, with severe face and neck allergic swelling. The airway is at risk and should be managed as for anaphylaxis.

Management

Allow the patient to adopt the most comfortable position for breathing and give oxygen (5 litres per minute) by facemask. The drugs are given in the following order:

  1. Adrenaline (epinephrine) 1:1000, 500 micrograms intramuscularly. Preloaded ‘Epipens’ or ‘Anapens’ are available for adult and child. You need to be familiar with whichever form is held in your office.
  2. Chlorpheniramine: 10 mg intravenously will counteract the effects of histamine.
  3. Hydrocortisone: 100-200 mgIV or im
  4. Intravenous Fluid: Only required if hypotension develops. A suitable regime would be 1 litre of normal saline infused over 5 minutes with continuous monitoring of the vital signs

The majority of epileptic fits do not require active intervention as the patient will usually recover spontaneously. All that is needed is sensible positioning to prevent the patient from damaging himself. Fits may be precipitated in a known epileptic by starvation, flickering lights, certain drugs such as methohexitone, tricyclics or alcohol or menstruation. They may also follow a deep faint.

Signs and Symptoms
  • Many epileptics have a preceding aura followed by sudden loss of consciousness with a rigid extended appearance and jerking movements.
  • Frequently they suffer from urinary incontinency and may bite their tongue.
  • There is a slow recovery with the patient feeling sleepy and dazed.

There may be a cause for the fit: trauma, tumour and alcohol withdrawal. Any adult should have a first fit fully investigated.

Status Epilepticus

Should the fit be repeated, the patient has entered the state of status epilepticus. This is an emergency and requires urgent control.

Management
  1. In a simple fit the patient should be placed in the recovery position when practicable and allowed to recover.
  2. If they enter Status Epilepticus. IV lorazepam 4 mg or IV diazepam 10-20 mg (in 5 mg boluses, 2 min between boluses, preferably as a lipid emulsion) usually aborts the fit.
  3. Beware respiratory depression: Assess cardiorespiratory function; clear and maintain airway and give O2 if available. It is worthwhile to place an IV cannula or a butterfly in any epileptic patient with less than perfect control, as stress is an important precipitant.
  4. Status Epilepticus should not be allowed to continue for more than 20 minutes as the mortality rate (up to 30%) and chance of permanent brain damage increases with the length of attack.

Hypoglycaemia is the diabetic emergency which may occur before the dentist. It is an acute and dangerous complication of diabetes and may result from a missed meal, excess insulin or increased calorific need due to exercise or stress. Most diabetics are expert in detecting the onset of hypoglycaemia themselves; however, some may lose this ability, particularly if changed from porcine to human insulin. Recognition of this state is essential and an acutely collapsed diabetic should be assumed hypo glycaemic until proven otherwise, e.g. by "BM" sticks or blood-glucose levels.

Diagnosis

Disorientation, irritability, increasing drowsiness, excitability or aggression in a known diabetic suggests hypoglycaemia. They often appear to be drunk.

Management
  • If conscious : Give glucose orally in any available form.

  • If unconscious : Protect airway. Place in recovery position. Establish IV access and give up to 50 ml of 20-50% dextrose. If available, 1 mg of glucagon i.m. may be used. Ensure help.

An acute asthmatic attack may be induced in a patient predisposed to bronchospasm by exposure to an allergen. Infection cold, exercise or anxiety.

Signs and Symptoms
  • Characteristically, the patient will complain of a tight chest and shortness of breath.
  • Examination will reveal breathlessness, with widespread expiratory wheezing.
  • The accessory muscles of respiration may be used to support breathing. If the patient is unable to talk you are dealing with a potentially fatal episode.
Management

Make use of the patient's own anti-asthmatic drugs, such as salbutamol inhalers. Ideally, this should be administered in the form of a nebulizer.

A do-it-yourself nebulizer can be fabricated from the patient's own inhaler pushed through the base of a paper cup. Repeated depressions of inhaler plunger will create an aerosol inside the cup which the patient can inhale. This will relieve most reversible airways obstruction. Steroids should be administered either as oral prednisolone, if the patient carries these with them or as IV hydrocortisone up to 200 mg IV.

This combination of salbutamol, steroids, and O2 will often completely resolve an attack: however. An urgent hospital admission is required for individuals who do not respond. Patients who are only partially responsive must having underlying irritants such as a chest infection either excluded or treated.

Be aware of the possibility of anaphylaxis mimicking acute asthma.

Remember adrenaline 0.5 ml 1:1000 s.c.

Management in dental practice

Keep the patient upright. Administer salbutamol either by inhaler or by nebulizer . Administer Oxygen. Give steroids.

If a complete response takes place it is reasonable to allow the patient to return home. If there is any doubt arrange for the patient to be seen at the nearest emergency.

The combination of delicate instruments and the supine position of patients for many dental procedures inevitably results in the risk of a patient inhaling a foreign body. Two basic scenarios are likely. depending on whether or not the item impacts in the upper or lower airway.

Upper airway

This will stimulate the cough reflex. which may be sufficient to clear the obstruction. A choking patient should be bent forward to aid coughing.

If the obstuction is complete or there signs of cyanosis in,

Conscious patient :
  • Support chest with one hand and strike between the scapulae with the heel of your other hand. Repeat up to 5 times.
  • If this fails carry out abdominal thrusts (Heimlich) by encircling victim with your arms from behind and deliver sharp upward and inward squeeze to create sudden expulsion of air. Repeat up to 5 times
  • Alternate 5 back blows with the 5 abdominal thrusts.
Unconscious patient :
  • Finger sweep to remove foreign body.
  • Abdominal thrusts with victim supine.
  • If all else fails cricothyroid puncture may preserve life if the obstruction lies above this level.
Lower airway

As only a segment of the lungs will be occluded this presents a less acute problem. It is also easier to miss. Classically this involves a tooth or tooth fragment slipping from the forceps and being inhaled, with the patient in a semi-upright position the object ends up in the right posterior basal lobe. Should this happen, inform the patient and arrange to have a chest radiograph taken as soon as possible. If the offending item is in the lungs, removal by a chest physician by fibre-optic bronchoscopy, is recommended, as this inevitably causes collapse and infection distal to the obstruction. Rarely, Lobectomy may be needed.

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