Medical Emergencies Flashcards
Epilepsy
There may be a brief warning (but variable)
Sudden loss of consciousness, the patient becomes rigid, falls, may give a cry, and becomes cyanotic (tonic phase)
After 30 seconds, there are jerking movements of the limbs; the tongue may be bitten (clonic phase)
There may be frothing from mouth and urinary incontinence
The seizure typically lasts a few minutes; the patient may then become flaccid but remain unconscious. After a variable time the patient regains consciousness but may remain confused for a while
During a convulsion try to ensure that the patient is not at risk from injury but make no attempt to put anything in the mouth or between the teeth (in mistaken belief that this will protect the tongue). Give oxygen to support respiration if necessary.
Do not attempt to restrain convulsive movements.
After convulsive movements have subsided place the patient in the coma (recovery) position and check the airway.
After the convulsion the patient may be confused (‘post-ictal confusion’) and may need reassurance and sympathy. The patient should not be sent home until fully recovered. Seek medical attention or transfer the patient to hospital if it was the first episode of epilepsy, or if the convulsion was atypical, prolonged (or repeated), or if injury occurred.
Medication should only be given if convulsive seizures are prolonged (convulsive movements lasting 5 minutes or longer) or repeated rapidly. Midazolam oromucosal solution can be given by the buccal route
Hypoglycemia
Insulin-treated diabetic patients attending for dental treatment under local anaesthesia should inject insulin and eat meals as normal. If food is omitted the blood glucose will fall to an abnormally low level (hypoglycaemia)
Hypoglycaemia should be excluded in any person with diabetes who is acutely unwell, drowsy, unconscious, unable to co-operate, or presenting with aggressive behaviour or seizures. Symptoms of hypoglycaemia in children include shakiness, pounding heart, sweatiness, headache, drowsiness, and difficulty concentrating. In young children, behavioural changes such as irritability, agitation, quietness, and tantrums, may be prominent.
In adults;
Aggression and confusion
Sweating
Tachycardia (heart rate >110 beats per minute)
Shaking and trembling
Difficulty in concentration/vagueness
Slurring of speech
Headache
Fitting
Unconsciousness
Management:
Assess patient
Administer O² 15L/min
If concious and cooperative:
10-20g oral glucose
(Repeated, if necessary after 10-15 minutes)
If unconcious and uncooperative:
1mg intra-muscular injection
Then 10-20g oral glucose when patient re-gains conciousness
If the patient does not respond or any difficulty is experienced, call for an ambulance
Anaphylaxis
Management:
Assess the patient
Call for an ambulance
Secure the patients airway and help restore blood pressure by laying the patient flat +/- raising their feet
Remove source of reaction
O² 15L/min
Adrenaline 0.5ml (1:1000)
If cardiac arrest follows, begin BLS
A severe allergic reaction may follow oral or parenteral administration of a drug. Anaphylactic reactions in dentistry may follow the administration of a drug or contact with substances such as latex in surgical gloves. In general, the more rapid the onset of the reaction the more profound it tends to be. Symptoms may develop within minutes and rapid treatment is essential.
Paraesthesia, flushing, and swelling of face
Generalised itching, especially of hands and feet
Bronchospasm and laryngospasm (with wheezing and difficulty in breathing)
Rapid weak pulse together with fall in blood pressure and pallor; finally cardiac arrest
Immediately call for an ambulance and begin initial anaphylaxis treatment.
Remove the trigger causing the anaphylactic reaction if possible. Place the patient in a comfortable position based on their signs and symptoms—lay the patient flat (with or without legs raised) to aid in the restoration of blood pressure, or in a semi-recumbent position for patients with airway and breathing problems (and no evidence of cardiovascular instability) to make breathing easier, or in the recovery position for patients who are unconscious and breathing normally; pregnant females should lie on their left side to prevent aortocaval compression.
Give intramuscular adrenaline/epinephrine as first line treatment for anaphylaxis, and assess response to treatment by monitoring vital signs (such as blood pressure, pulse, respiratory function, and level of consciousness) and auscultate for wheeze. A repeat dose of intramuscular adrenaline/epinephrine should be given after a 5-minute interval if there is no improvement in the patient’s condition. Patients who have no improvement in respiratory and/or cardiovascular problems despite 2 appropriate doses of intramuscular adrenaline/epinephrine should have their care escalated quickly. Continue to give intramuscular adrenaline/epinephrine at 5-minute intervals while life-threatening cardiovascular and/or respiratory features persist.
High-flow oxygen and intravenous fluids are also used for initial treatment of anaphylaxis.
Angina/MI
Progressive onset of severe, crushing pain in the centre and across the front of chest; the pain might radiate to the shoulders and down the arms (more commonly the left), into the neck and jaw or through to the back
Shortness of breath
Increased respiratory rate
Skin becomes pale and clammy
Nausea and vomiting are common
Pulse might be weak and blood pressure might fall
Management:
Assess the patient
Administer 100% oxygen
Flow rate: 15 litres/minute
Administer glyceryl trinitrate (GTN) spray, 2 puffs (400 micrograms per metered dose) sublingually, repeated after 3 minutes if chest pain remains
If the patient does not respond to GTN treatment then the priority is to transfer the patient to hospital as an emergency.
Call for an ambulance.
Administer aspirin, 300 mg dispersible tablet, orally
NB: The aspirin tablet should be chewed or dispersed in water.
If aspirin is given, send a note with the patient to inform the hospital staff.
If the patient becomes unresponsive, check for signs of life (breathing and circulation), and if there are no signs of life or no normal breathing, initiate basic life support (BLS)
Stable angina will abate with rest
Unstable angina won’t abate with rest > GTN spray (3 minutes, then a second dose)
If no resolution of symptoms, 300mg of crushed aspirin and call for an ambulance
BLS
Look for danger
Check for a response: shout and shake “hello can you hear me”
Shout for help
Make sure airway isn’t blocked
Ear to mouth and look down chest to check for 10 seconds to assess breathing
Start chest compressions
30/2 @ 120/minute
5-6 centimeters
Call ambulance; tell location, need AED, oxygen and bag valve mask, name, phone number, patient going into cardiac arrest
Remove clothing/shave/dry pad sites
15L/o2/minute
Asthma
Patients with asthma may have an attack while at the dental surgery. Most attacks will respond to 2 puffs of the patient’s short-acting beta2 agonist inhaler such as salbutamol 100 micrograms/puff; further puffs are required if the patient does not respond rapidly. If the patient is unable to use the inhaler effectively, further puffs should be given through a large-volume spacer device (or, if not available, through a plastic or paper cup with a hole in the bottom for the inhaler mouthpiece). If the patient has features of severe or life-threatening acute asthma, or the response remains unsatisfactory, or if further deterioration occurs, then the patient should be transferred urgently to hospital. Whilst awaiting transfer, oxygen should be given with salbutamol 5 mg or terbutaline sulfate 10 mg by nebuliser; if a nebuliser is unavailable, then 2–10 puffs of salbutamol 100 micrograms/metered inhalation should be given (preferably by a large-volume spacer), and repeated every 10–20 minutes if necessary. If asthma is part of a more generalised anaphylactic reaction, an intramuscular injection of adrenaline/epinephrine (as detailed under Anaphylaxis) should be given.
