Medical Emergencies Flashcards
What are the steps in patient assessment in a medical emergency?
- AIRWAY
- BREATHING
- CIRCULATION
- DISABILITY
- EXPOSURE
Is patient awake? Are they unwell? How do they feel?
What does it suggest if a patient can speak to you?
No airway problem
What are the signs of airway obstruction?
See-saw respirations
Central cyanosis- blue tongue
Complete obstruction- no breathing sounds
Partial- noisy breathing
What can be done if a patients airway is not patent?
Use an oro-pharyngeal airway
How is an OPA sized?
Measure from angle of jaw to vertical height of incisors
-> usually orange for males and green for females
What is the normal respiratory rate?
12-20 breaths per min
What are the common causes of breathlessness in patients?
Increased demand
Infection
Inflammation in airways
How is breathing assessed?
Assess breathing rate- look for chest rising/falling, listen for breathing sounds
-> check for equal expansion on both sides of chest
Assess rhythm
Assess depth
Why is it important not to tell the patient you are counting their respiratory rate?
They may alter it
-> ask to feel pulse and put hand on shoulder at same time to feel rate
What can be done to help patients who are struggling to breathe?
Place patient in tripod postion- allows opening of intercostal muscles
Give oxygen- 15l/min
Bronchodilators- salbutamol
What is the normal resting HR?
60-90 bpm
What are the causes of irregular pulse/circulation?
Arrhythmias- if you suspect this end to A&E
ACS- unstable angina, STEMI, NSTEMI
Heart failure
Loss of fluid/blood
What checks can help us recognise circulatory issues?
Check pulse- assess regularity, strength, speed
-> count it against clock
Capillary refill test- press nail bed for 5 sec
-> reperfusion should occur within 2 secs
Check limb temp and colour
-> are the hands blue, pink, pale, mottled
-> >37.8 is a fever
What are the different ways of checking pulse? What is the minimum BP required to detect each?
Pulse on wrist- minimum systolic of 70mmHg
Brachial pulse- minimum systolic of 60mmHG
Carotid- minimum systolic of 50mmhg
What is meant by disability in a medical emergency assessment?
Gross neurological function deficit
What are the causes of disability/unconsciousness?
Hypoxia
Hypercapnia
Drugs and alcohol
Brain injury- cerebral hypo perfusion
Hypoglycaemia
What are the steps in recognising disability? (ACVPU)
Alert- is patient responding
Confusion
Verbal stimuli response
Painful pressure- apply pressure to trapezius and see if they try to move your hand away
Unresponsiveness- to all/any stimuli
-> assess pupils with light- do they respond equally in terms of time and size
What is done at the exposure stage of patient?
Check colour of hands , check neck vessels, check continence (have they soiled themselves)
What are the emergency conditions that a dentist may have to deal with?
- ANAPHYLAXIS
- ANGINA/MI
- ASTHMA
- CARDIAC ARREST
- HYPOGLYCAEMIA
- SEIZURES
For what patients is oxygen given in an emergency situation in the dental setting?
For all emergencies (given in combination with any emergency drug)
*harm from over-oxygenation only occurs over long periods not seen in dental setting
How is oxygen administered to patients?
Use non-rebreathing mask which delivers 90% oxygen at a rate of 15 litres/min (one tank lasts 25 min)
Put finger in bag to allow it to inflate/place finger over green valve
Place over patients face and tighten straps
What is anaphylaxis?
Severe systemic hypersensitivity reaction
-> can result in shock- inability to perfuse organs/tissues
What are the features of ABCDE assessment in patient with anaphylaxis?
A- swelling, hoarsness
B- increased rate, wheezing due to bronchoconstriction
C- increased rate, hypotension due to vasodilation, hypovolaemia
D- loss of consciousness?
E- rash, swelling , abdominal pain/cramps, diarrhoea
When do we provide treatment for patients suffering from anaphylaxis
- life-threatening airways = airway swelling/hoarseness, periorbital swelling, swollen lips and tongue
- Life threating breathing – peripheral cyanosis (84% oxygen saturation) lips and finger nails blue
- Life threating Circulatory – can’t palpate radial pulse (= less than 70 systolic BP)
- If in any doubt
What is used to treat anaphylaxis?
IM adrenaline (1:1000 concentration)
-> 0.5mg
- Kits have 2 doses, only use half
What are the actions of adrenaline systemically?
- Peripheral vasoconstrictor
- Central vasodilator
- Bronchodilator
- Improves efficacy of myocardium
- Increases HR
What position should the patient be in when administering adrenaline?
Lie down with legs above head (better response as it helps blood get into central circulation)
OR
With patient sitting- if breathing issue
What are the steps in administering adrenaline?
- Traction applied to the side of the thigh
- Inject and advance into the muscle (can feel the change in texture)
- Aspirate - if blood – advance another 1mm and aspirate again
- Inject
- Once injected remove needle ½ of the way and let go of traction
- Remove the needle fully (prevents capillary action removing some of the drug)
What do you do if patient does not improve after 5 mins of administering adrenaline?
Give another dose every 5 mins (different locations on thigh)
Why do healthy patients experience no chest pain on exertion?
As less than 1/3rd of the diameter of coronary arteries are obstructed by atheroma
What is stable angina?
Chest pain caused by ischaemia which is resolved by rest
What is unstable angina? What causes it?
Presents as pain at rest
-> Fibrous membrane of the plaque in a coronary artery ruptures and the contents of the plaque fills the coronary arteries (close to an entire blockage
-> Blood leaks from the plaque and clotting of the blood occurs = thrombosis
-> Vasoconstriction occurs due to inflammation which can lead to Artery spasm
How is unstable angina treated?
2 puffs of GTN spray sublingually- 400 mcg per puff
-> can be repeated
What are the actions of GTN?
Dilates veins- reducing preload to the heart
-> reduces workload of myocardium
Provides symptomatic relief but does not treat underlying issue
When should GTN be avoided
If patient has low BP as it can cause lack of consciousness
What happens if GTN is not effective within a few minutes?
Treat as an MI, especially if patient feels episode is different from normal
What are the features of the ABCDE assessment in patients suffering from an MI?
A- no issue, they can talk
B- Increased
C- Increased
D- alert
E- pale, hot/sweaty, central crushing chest pain
How is an MI treated in emergency in dental setting?
Chew 1 aspirin tablet 300mg or crush and place under tongue in edentulous patients
-> aim to provide this within 10min of onset
-> don’t give patient any water for 10 min to avoid diluting drug or washing it into gut
What is the purpose of aspirin?
Reduces platelet aggregation
Where should different MIs be sent?
STEMI- jubilee
NSTEMI- Royal infirmary (thrombolysis)
What are the features of mild and moderate asthma attack?
A: normal
B: chest tightness and normal respiratory rate
C: normal heart rate
How is a mild and moderate asthma attack treated?
2 puffs salbutamol (100mcg per puff)
-> patient holds breath for 10 secs between
-> causes bronchodilation
what are the features of an acute/severe asthma attack?
B- >25 breaths per min or audible wheeze
C- HR- >115bpm
How is acute/severe asthma attack treated?
As patient cannot hold breath
-> Fill spacer device with 10 puffs and get them breath using it for up to 20 secs
What are the features of life threatening asthma (moribund patient)
Breathing rate- less than 8 per min
HR- <40bpm
How is life threatening asthma treated?
Intubate and attach BVM (volume 1.5L)
-> phone ambulance
Why is a BVM volume 3x that of the tidal volume? What issue can this cause?
Easy way to get higher air pressures in life threatening asthma conditions
Only squeeze hard enough to see chest rise or else air will reach stomach and cause aspiration of contents
What are the complications of salbutamol?
- Tremor
- tachycardia
- tachyarrhythmias (rare)
What are the features of the ABCDE assessment in a hypoglycaemic patient?
A: initially talking
B: initially increased rate
C: initially increased rate
D: initially alert
E: irritable, confused, pale
-> usually caused by inflammation, infection, allergy on top of underlying diabetes
How is hypoglycaemia treated in emergency?
If conscious whilst they still have swallowing reflex- give 3 glucose tablets (can be difficult to do), gel is better (sticks to lips and gums)
If consciousness lost (<3)- use glucagon 1mg
-> combine fluid and powder (do not shake)
-> use same IM injection technique as before
When is oxygen used in seizures?
Place oxygen mask next to the px whilst they are seizing and then put on the patient when they have stopped
-> most stop within 2 mins
What are the features of the ABCDE assessment when a patient is having a seizure?
A: always assume compromised (head tilt chin lift)
B: variable - assess colour of patient
C: variable - assess veins on back of hand
D - unresponsive
E – seizure activity, incontinence
What is the treatment for seizure in emergency in dental setting?
Midazolam- 10mg into buccal sulcus
What is the treatment for seizure in emergency in dental setting?
Midazolam- 10mg into buccal sulcus
What are the side effects of midazolam when used to treat seizure in an emergency?
Respiratory depression- hypoventilation
Hypotension
Sedation = loss of airway tone
-> do not attempt to reverse
What are the features of an ABCDE assessment for syncope (faint)?
A – compromised
B – reduced rate
C – reduced rate and pressure
D – unresponsive
E – pale and clammy
-> raise legs- if there is no response within 5 mins this is not a fainting episode
