Medical Emergencies Flashcards
What could cause upper airway obstruction at dentist?
increased blood and saliva for prolonged periods
LA effect pharyngeal reflexes
dental equipment
What are the most common causes of upper airway obstruction at dentist?
- inhalation of foreign object
2. laryngospasm (vocal cord spasm = hard to breath/speak)
What symptoms suggest upper airway obstruction?
- sudden onset
- coughing & spluttering
- complaint of difficulty breathing
Symptom of larynx blocked?
can’t breath
Symptom of main bronchus blocked?
hard to breath
How do you assess upper airway obstruction?
LOOK - colour of pt, ease of breathing, paradoxical chest/abdominal movt (one side rises more / chest moves inwards on inhalation), accessory m. used)
LISTEN - absence of or additional sounds
What are the SIGNS of upper airway obstruction?
- paradoxical chest/abdominal movt (one side rises more / accessory m. used) - seesaw movt.
- accessory mm used
- central cyanosis - late sign
What are SIGNS of PARTIAL upper airway obstruction?
- inspiratory stridor (if obstruction at or above larynx)
- expiratory wheeze (likely if lower airways obstruction)
- gurgling (suggests liquid / semi-solid foreign material in upper airway)
- snoring (tongue / palate partially blocks pharynx)
How do you manage upper airway obstruction?
- head tilt / chin lift or jaw thrust
- remove visible foreign body
- airway adjuncts (guedel airway)
- high flow oxygen
What are commonest conditions that affect breathing?
- hyperventilation
- asthma
- (angina)
- (heart failure)
How do you assess breathing in ABCDE?
- assess Airway first
- determine if life threatening condition (asthma, angina, heart failure)
- LOOK - sweating, central cyanosis, use of accessory m., abdominal breathing
- count respiratory rate
- LISTEN - stridor, wheeze, gurgling
- FEEL - air on cheek
What is a normal respiratory rate in adults / children?
Adults = 12-20 breaths /min Children = 20-30 breaths /min
Which is worse - an increase of decrease in respiration?
decrease
How do you manage breathing issues?
- bag & mask
- pocket mask
- call 999
What is hyperventilation?
Minute ventilation exceeds metabolic demands resulting in haemodynamic changes.
Blowing off too much CO2
Can be acute or chronic
Linked to panic disorder
What are symptoms of hyperventilation?
- shortness of breath / wheeze
- chest pain / palpitations
- belching / dry mouth
- dizziness
- peripheral paresthesia / circumoral numbness
How do you manage hyperventilation?
- reassure pt
- paper bag / cupped hands
- small dose of benzodiazepines eg lorazepam (unlikely at dentist)
- consider anxiety mgt
Give an example of a benzodiazapine given in hyperventilation?
lorazepam
Why might giving a benzodizapine be bad if you think pt is hyperventilating?
Benzodiazapines depress respiratory system.
Bad if another cause - asthma, angina
Asthma - two of more of what symptoms must be present to be diagnosed with asthma?
wheeze
breathlessness
chest tightness
cough
When are asthmatic symptoms likely to be worse?
- at night / early morning
- after exercise
- cold air
- allergen exposure
- after taking aspirin, beta blockers
- history of atopy (hyperallergic)
- family history of atopy or asthma
Why does aspirin make asthma worse?
- aspirin increases leukotrienes (because COX blocked, therefore decrease in prostaglandin / thromboxane pathway, increase in leukotrienes pathway)
- leukotrienes increase broncial muscle contraction
- which increases wheezing / shortness of breath
How does aspirin work?
Membrane phospholipids
I
arachidonic acid
I (COX) I (5-lipoxygenase)
Prostoglandins (inflam) Leukotrienes
Thomboxane (platelet aggregation)
What is atopy?
hyperallergic
What are the risk factors for severe asthma?
- previous near fatel asthma (admitted to hospital)
- Previous ventilation or respiratory acidosis
- previous hospitalisation (esp in past year)
- 3+ classes of asthma medication
- heavy use of beta2 agonist (asthma not controlled)
- brittle asthma (don’t respond to treatment, inc inhaled treatments, high dose corticosteroids, long acting beta2 agonists)
What psychological issues are linked to asthma?
- non compliance (treatment)
- DNA appointments
- reduced GP contact
- freq home visits
- self discharge from hospital
- psychosis / depression / self harm
- denial
- alcohol abuse
- obesity
- employment issues
- income issues
- social isolation
- childhood abuse
- severe domestic / marital / legal stress
What could cause acute asthma at dentist?
- LA with vasoconstrictors (sulphites in vasoconstrictors = bronchospasm)
- GA / sedatives (avoid - can cause asthma / respiratory failure)
- avoid penicillin as many asthmatics are allergic
- NSAIDS
- aspirin, barbituates, beta-blockers, cyanoacrylates, mefanamic acid, morphine, pancuronium, suxamethonium
What drugs should be avoided at dentist for asthmatic?
- LA with vasoconstrictors (sulphites in vasoconstrictors = bronchospasm)
- GA / sedatives (avoid - can cause asthma / respiratory failure)
- avoid penicillin as many asthmatics are allergic
- NSAIDS
- aspirin, barbituates, beta-blockers, cyanoacrylates, mefanamic acid, morphine, pancuronium, suxamethonium
What are symptoms / signs of MILD asthma?
- increase wheeze
- complaints of chest tightness
- increased respiratory rate
- tachycardia
What are symptoms / signs of MODERATE asthma?
- same as mild, but increased symptoms
- and increased freq of attacks
- no symptoms of severe
- wheeze
- complaints of chest tightness
- increased respiratory rate
- tachycardia
What are symptoms / signs of SEVERE asthma?
- inability to complete sentences in one breath
- respiratory rate >25 breaths/min
- tachycardia >110 beats/min (normal = 70)
- use of accessory muscles
What are symptoms / signs of LIFE THREATENING asthma?
- cyanosis
- respiratory rate
How do you manage asthma?
- ABCDE
- high flow O2 (10-15L/min)
- salbutamol - 4-6 puffs in spacing device. Repeat every 10mins
- nebuliser - with salbutamol
- 999 if severe
What drug goes in nebuliser?
salbutamol
How many puffs of which drug should be put into spacing device during asthma attack?
4-6 puffs salbutamol
What emergencies affect cardiovascular system at the dentist?
Syncope - most common
Heart disease - angina, MI
Anaphylaxis
What is the most common cardiovascular issue in the dental surgery?
syncope
What forms part of the cardiovascular examination in an emergency?
Look at colour of hands - blue, pink, pale, mottled?
Assess temp of pt peripheries
Capillary refill time - should be
Signs and symptoms of syncope?
- pale, sweaty, clammy
- light headedness
- slow pulse rate (may be rapid)
- low BP
- (loss of consciousness)
What do you do if pt fainted?
- reassure pt
- lie back, legs raised
- Oxygen 10-15L/min
- loosen tight clothing
- monitoring breathing and circulation
What is recovery rate for a faint?
Fast.
If not a quick recovery, could be another cause (eg MI)
What are SYMPTOMS of acute chest pain?
- central crushing chest pain (not always)
- may radiate to left arm, neck, back, epigastrium (pain may only be in jaw, arm, epigastrium)
- nausea, vomiting
- sweating
- difficulty breathing / shortness of breath
What is the sign of an inferior heart attack?
Slow pulse
What is management for angina?
- reassure pt
- oxygen
- Nitrate - GTN (nitroglycerin)- spray / tablets under tongue
- 999 if prolonged
What is management for MI?
MONASH!
- Monitor pt
- Oxygen
- Nitrate (GTN)
- Aspirin (300mg PO)
- Help - 999
What dose of aspirin should be given in MI?
300mg PO
What is anaphylaxis?
Hypersensitivity reactions
- mild symptoms - urticaria, pruritis (itching)
- severe symptoms - hypotension, airway compromise
Acute, life threatening, IgE antibody-antigen mediated hypersensitivity reaction
Life threatening airway +/- breathing +/- circulation problems
Linked to skin and mucosal changes
What is pruritis?
itching
What % of pop is affected by anaphylaxis?
up to 15%
Common causes of anaphylaxis?
Food - shellfish, nuts, milk products, eggs, nitrates/nitrites (eg bacon, processed meat, some veg)
Drugs - penicillins, muscle relaxants, NSAIDS, opiates
Latex
Radiographic contrast media
Additives in medicines (inc topical drugs)
What acronym covers symptoms of anaphylaxis? What are the symptoms of each letter?
FAST
Face - rash, swelling, urticaria, erythema, rhinitis (runny nose), conjunctivitis, red/pale face
Airway - hard to breath, swallow, speak, tongue swelling, hoarse voice, bronchospasm (leads to wheeze), upper airway oedema (leads to stridor)
Stomach - pain, nausea, vomiting, diarrhoea
Total body - rash, swelling, weakness, pallor/cyanosis, sense of doom, loss of consciousness, hypotension
What are the facial symptoms of anaphylaxis?
rash, swelling, urticaria, erythema, rhinitis (runny nose), conjunctivitis, red/pale face
What are the airway symptoms of anaphylaxis?
hard to breath, swallow, speak, tongue swelling, hoarse voice, bronchospasm (leads to wheeze), upper airway oedema (leads to stridor)
What are the stomach symptoms of anaphylaxis?
pain, nausea, vomiting, diarrhoea
What are the total body symptoms of anaphylaxis?
rash, swelling, weakness, pallor/cyanosis, sense of doom, loss of consciousness, hypotension
How do you manage anaphylaxis?
- ABCDE
Airway - ensure patent, give oxygen
Breathing - assess respiratory rate, consider salbutamol in spacer device
Circulation - lie pt flat, check pulse and BP
Adrenaline
- epi-pen - 0.3mL or 1:1000 (300mcg)
- IM - 0.5mL of 1:1000 (500mcg)
- repeat after 5 mins (or 10 / 15 mins)
Disability - assess conscious level
Exposure - extent of rash
MUST go to hospital
What are the signs of hypoglycaemia?
- sweating, clammy, trembling
- rapid heartbeat
- poor concentration
- slurred speech, can’t complete sentences
- aggression
- fitting
- loss of consciousness
How do you confirm a diagnose of hypoglycaemia?
automated blood glucose measurement device
aka glucometer
What is a normal blood glucose level?
4-7mmol/L before food
What blood glucose level suggests hypoglycaemia?
How do you treat hypoglycaemia?
- oral glucose - drink, tablets, glucose gel
- can’t swallow - buccal glucose gel
- IM glucagon (glycogen to glucose in liver)
How long will recovery after glucagon IM given in hypoglycaemia?
10mins
What glucagon dose should be given in hypoglycaemia?
Adults
- 1mg (IM)
Children 8yrs+ / 25kg+
- 1mg (IM)
Children
What is epilepsy?
- common, chronic neurological disorder
- recurrent seizures due to abnormal neuronal activity in brain
- can be unprovoked, flashing lights, hyperventilation
- mild = disorientation
- moderate = collapse
- severe = consulsions
What are the types of epileptic seizure?
Simple partial seizure
- hallucination, confusion, disorientation
Complex partial seizure
- may become unconscious
Tonic-clonic seizure
- unconscious, then convulsions
What is a Simple partial seizure?
hallucination, confusion, disorientation
What is a complex partial seizure?
may become unconscious
What is a tonic-clonic seizure?
unconscious, then convulsions
What are signs / symptoms of tonic-clonic seizure?
- may see aura before seizure
- tonic phase - brief cry before loss of consciousness, rigid extended body
- clonic phase - widespread jerking movt
May also have
- tongue biting, incontinence, cyanosis
What is speed of recovery post-epileptic fit?
Slow.
pt may be confused.
How do you manage epileptic fit?
ABCDE
- circulation - may be hypotensive
- disability - check glucose (pt with hypoglycaemia may have a fit)
MOVE
- Monitor - reassess ABCDE
- Oxygen
- Verify help coming - prepare doc for transfer
- Emergency action - recovery position, away from sources of injury
What do you do in self-terminating seizure?
- recovery position
- if know epileptic, check they are accompanied
- may not want to go to hospital
What do you do in a prolonged seizure?
- ensure good airway
- consider buccal or intranasal midazolam
- 999 (may not need if it happens a lot)
What drug might you give in prolonged seizure and what are dose levels?
Midazolam
1-5yrs = 5mg
5-10yrs = 7.5mg
10yrs+ = 10mg
NB only give if confident
