26.3 Medical emergencies in dentistry Flashcards
What are the 3 levels of training for medical emrgencies in dentistry?
- BLS: annually for all dentists
- ILS: for dentists providing sedation
- ALS: highest level of training, for dentists working in a hospital setting, 2 day course and exams
What medical emergencies might occur in dental practice?
- Vasovagal syncope (most common), fainting
- Angina
- Hypoglycaemia
- Epileptic seizures
- Choking
- Asthma attack
- Anaphylaxis
- Cardiac arrest
- Adrenal insufficiency
What are the normal obs for adults and children?
What system do hospitals use to detect deteriorating patients?
National early warning score (NEWS)
How do you assess airway obstruction?
- Look for signs of obstruction e.g. use of accessory muscles, see-saw respirations, central cyanosis
- Complete airway obstruction = no noise
- Partial obstruction:
Inspiratory stridor: obstruction at laryngeal level
Expiratory wheeze: obstruction of lower airways
Gurgling: liquid or semi-solid in upper airway
Snoring: partial occlusion of pharynx
How can you see if anything is blocking the throat?
Look down the airway, use suction to improve visibility
Describe the airway opening manoeuvres.
- Head tilt/chin lift or jaw thrust (Not if C-spine fracture suspected)
- Remove visible foreign body (suction)
- Simple airway adjuncts e.g. oropharyngeal airway (Guedel airway- measured from mouth to angle of mandible) nasopharyngeal airway
How should oxygen be delivered to patients?
If oxygen saturation is 92% or below give 15 litres of oxygen per minute via non-rebreather mask.
What are signs of respiratory distress?
- Sweating
- Central cyanosis (blue tinge to membranes)
- Use of accessory muscles of respiration
- Chest expansion unequal, shallow breaths
- Breath sounds: gurgling, stridor, wheeze
- Oxygen saturations
What is the difference between a rebreather mask and a bag valve mask?
- Rebreather: conscious/breathing patients
- Bag valve mask: patient is not breathing at all, used in cardiac arrest, should be able to see chest rising
What is the difference between a rebreather mask and a bag valve mask?
- Rebreather: conscious/breathing patients
- Bag valve mask: patient is not breathing at all, used in cardiac arrest, should be able to see chest rising
How do you assess circulation?
- Colour: blue/pink/pale/mottled
- Is limb temperature cool or warm
- Capillary refill: pressure for 5 seconds on chest, colour should return in 2 seconds
- Central capillary refill: press collarbone until it blanches, colour should return in 1-2 seconds
- Peripheral capillary refill: press fingernail, colour return in 3 seconds
- Radial or carotid pulse
- Blood pressure
How do we assess disability/consciousness?
- Glasgow coma scale (medicine not dent)
- CAVPU: confusion, alert, voice, pain, unresponsive
After reaching D in ABCD what should you do?
- Review and treat ABCs
- Check pt drug record to see if there is a reason they have become unwell
- Check pupils: size, equal, reactive to light
- Assess blood glucose
- If unconscious, place in recovery position
- Temperature
- Rashes, bruises, bleeding
What should you do if a patient goes intro adrenal crisis?
- Not enough corticosteroids
- Symptoms: extreme weakness, significant drop in BP, drowsiness, mental confusion
- Call 999 and state addisonian crisis
- If you are competent and pt carries emergency kit, deliver IM hydrocortisone 100mg
- Surgery is a major physiological stressor, patients with adrenal insufficiency normally double their steroid dose before treatment
What is anaphylaxis, how does it present?
- Severe, life threatening, generalised type 1 hypersensitivity reaction
- Tachycardia, increased resp rate, hypotension, bronchospasm, urticarial rash and angiodema
- Vasodialtion causes hypovolaemia leading to low BP = collapse
- Upper aiway oedema and bronchospasm = stridor, wheeze, hoarse voice
- Respiratory arrest can lead to cardiac arrest
- Abdominal pain, vomiting, diarrhoea, sense of impending doom
How do you manage anaphylaxis?
IM adrenaline
IM adrenaline for adults and children over 12.
500 micrograms IM (0.5ml)
IM adrenaline for children aged 6-12.
300 micrograms IM (0.3ml)
IM adrenaline for children aged 6 months - 6 years.
150 micrograms IM (0.15ml)
IM adrenaline for children under 6 months.
100-150 micrograms IM (0.1-0.15ml)
When should you repeat adrenaline in anaphylaxis?
At 5 minute intervals if the patient is not responding
How is IM adrenaline delivered?
- Snap glass vial open
- Draw up dose
- Inject into vastus lateralis muscle (thigh)
- Don’t aspirate for IM injection
- Insert needle at 90 degree angle using dart like action
- Call 999 as soon as anaphylaxis is recognised
What are the signs of an asthma attack?
- Increases heart rate
- Increased resp rate (greater than 25)
- Cannot complete sentences
What are the signs of a life-threatening asthma attack?
- May have silent chest
- Cyanosis
- Poor respiratory effort
- Arrythmia
- Hypotension
- Exhaustion
- Altered consciousness
How is an asthma attack treated?
- Salbutamol/Ventolin inhaler: 1 puff every 60-90 seconds
- Use a spacer
- Oxygen (15 litres per minute)
- Depending on setting (e.g. hospital) may provide a nebuliser
- Call 999 if severe/life threatening, or if unsatisfactory/no response to tx
What is angina?
- Partial obstruction of the coronary arteries
- Causes central crushing pain which may radiate to the back or down the arm (women tend to have back pain)
- If GTN spray resolves pain it is likely angina rather than MI
What is an MI?
- Complete infarction of coronary vessels, no blood flow to the heart
- Life threatening
- If GTN spray has no effect assume MI
- Oxygen and 300mg aspirin (chew)
- Hospital setting: analgesia, IV morphine and anti-emetic
How do you manage a choking patient?
- Recognise choking: pt can’t talk, absent cough, looks panicked, may walk off
- 5 back blows, 5 abdominal thrusts
- If they lose consciousness, begin CPR
What are the causes of seizures?
- Febrile convulsions in paediatric patients (fever)
- Epilepsy/status epilepticus
- Neurological event e.g. stroke
- Faint
What is the management for a patient having a seizure?
- Remove any danger surrounding the patient to ensure their safety
- Administer high flow oxygen (15 litres per minute)
- Cool them down if they are warm
- Monitor and maintain ABC
- Seizures lasting longer than 5 minutes, or having several repeated seizures, require buccal midazolam (a benzodiazepine):
What is classed as hypoglycaemia?
Blood sugar <4mmol/L
What are the symptoms of hypoglycaemia?
- Sweating
- Shaking
- Hunger
- Palpitations
- Headache
- Nausea
- Confusion
- Drowsiness
- Odd behaviour
- Speech difficulty
- Incoordination
Pts often self recognise symptoms
Take capillary blood glucose if available.
What is the management for hypoglycaemia in conscious patients?
What is the management for hypoglycaemia in unconscious patients?
IM glucagon must be given through the skin, cut clothes off if necessary.
How do you manage vasovagal syncope?
- Very common (stress, patients on anti-hypertensives, Beta blockers)
- Caused by an initial tachycardia, then the vagus nerve kicks in, over does it causing a massive hypotension
- Some patients can have seizures in bad faints
- Lay flat
- Raise legs
- Glucose drink
What is red-flag sepsis?
- Extreme, life-threatening response to infection
- Immune system overreacts
- Can lead to organ failure
- E.g. dental abscess/infection can lead to sepsis
- Call 999
What is the difference between red flag and yellow flag sepsis?
How do you manage cardiac arrest?
- Call 999
- Start CPR immediately
- If indicated, defibrillation should be attempted as soon as possible (within 3 minutes)
CPR at 100bpm, 2/3rds the depth of the chest.
Adults: 30 compressions, 2 breaths
Children: 15 compressions, 2 breaths
Alternative defibrillator pad placement if pt has a pacemaker. Cannot place pad directly on that area.
Pads need to go on dry skin. Excess hair needs to be shaved.
