Medical Emergencies in Dental Practice Are Uncommon but Can Occur at Any Time

ARTICLE CORE CPD: Medical ONE HOUR emergencies: the drug box, equipment and basic principles By M. Greenwood1 and J. G. Meechan2 INTRODUCTION Medical emergencies in dental practice are uncommon but can occur at any time. All members of the dental team need to be aware of their role in the event of a medical emergency and should be trained appropriately with regular practice sessions. In December 2013, the Resuscitation Council (UK) provided up to date information regarding a minimum equipment and drug list for medical emergencies in dentistry. Quality standards for cardiopulmonary resuscitation (CPR) practice and training have been updated.1 It is evident ©iStockphoto/Thinkstock from the updated guidance that there is an increased emphasis on the importance of CPR Table 1 Contents of the emergency drug box and routes of administration in the dental setting. Anticipation of potential medical Drug Route of administration emergencies that might arise should be highlighted by taking a thorough medical Oxygen Inhalation history. A risk assessment should be made by Glyceryl trinitrate (GTN) spray (400 micrograms Sublingual considering the patient’s American Society per actuation) of Anaesthesiologists (ASA) classification category. The ASA classification is Dispersible aspirin (300 mg) Oral (chewed) summarised below. If medication is normally Salbutamol aerosol inhaler (100 micrograms Inhalation used, a check should always be made to per actuation) ensure that this has been taken as usual. Adrenaline injection (1:1000, 1 mg/ml) Intramuscular ■ ASA I healthy ■ ASA II mild systemic disease – no Glucagon injection (1 mg) Intramuscular/subcutaneous functional limitation Oral glucose solution/gel (GlucoGel)* Oral Midazolam 10 mg or 5 mg/ml (buccal or 1Consultant/Honorary Clinical Professor, Infiltration/inhalation intranasal) 2Senior Lecturer/Honorary Consultant, School of Dental Sciences, Newcastle *Alternatives: two teaspoons of sugar/three sugar lumps; 200 ml milk; non-diet Lucozade 50 ml; Coca- University Cola non-diet 90 ml – if necessary this can be repeated at 10-15 minutes 11 BDJ Team BDJ Team www.nature.com/BDJTeam © 2014 Macmillan Publishers Limited. All rights reserved ARTICLE Table 2 Suggested minimum equipment for medical emergency Table 3 The ABCDE approach to management (adapted from Resuscitation Council [UK]) an emergency patient Oxygen A Airway Glyceryl trinitrate (GTN) spray (400 micrograms per actuation) B Breathing Dispersible aspirin (300 mg) C Circulation Salbutamol aerosol inhaler (100 micrograms per actuation) D Disability (or neurological status) Adrenaline injection (1:1000, 1 mg/ml) E Exposure (in dental practice, Glucagon injection (1 mg) to facilitate placement of AED Oral glucose solution/gel (GlucoGel)* paddles) or appropriately exposing parts to be examined Midazolam 10 mg or 5 mg/ml (buccal or intranasal) ■ ASA III severe systemic disease – definite All emergency medical equipment should be If the patient is conscious, ask them how functional limitation latex-free and single-use wherever possible. they are. This may give important information ■ ASA IV severe disease – constant threat to about the problem (for example, the patient life STAFF TRAINING who cannot speak or tells you that they have ■ ASA V moribund Staff should be trained in the management chest pain). If the patient is unresponsive, the ■ ASA VI patient being ventilated for organ of medical emergencies to a level that patient should be shaken and asked ‘Are you donation purposes. is appropriate to their level of clinical all right?’ If they do not respond at all, have responsibility. This training should be updated no pulse and show ‘no signs of life’ they have THE EMERGENCY DRUG BOX on at least an annual basis. It is important had a cardiac arrest and should be managed Patients should only undergo dental treatment that new members of staff have medical as described later. They may respond in a in situations where appropriate equipment emergency training incorporated into their breathless manner and should be asked ‘Are and drugs are available and have not passed induction programme. A full record should you choking?’3 their expiry date. be kept of training. Staff should know who A minimum list of drugs to be included in to contact in the event of help being required Airway (A) – assessment and the emergency drug box is summarised and designated emergency phone numbers management in Table 1. The list is based on that given in should be readily available. Airway obstruction is a medical emergency the Resuscitation Council (UK) document and must always be managed quickly. Usually, on medical emergencies and resuscitation THE ‘ABCDE’ APPROACH a simple method of clearing the airway is all in dentistry.2 Medical emergencies can often be prevented that is needed. A head tilt, chin lift (Fig. 1) The Resuscitation Council (UK) by early recognition. Signs such as abnormal or jaw thrust (Fig. 2) will open the airway. recommends that such kits should be patient colour, pulse rate or breathing can Patients who are suddenly unable to speak are standardised.2 Wherever possible, they signal an impending emergency. in real danger and establishing a patent airway recommend that drugs in solution should It is important to have a systematic is critical. It is important to remove any visible be carried in a pre-filled syringe or kit. All approach to an acutely ill patient and to foreign bodies, blood or debris and the use of drugs should be stored together, ideally in a remain calm. The principles are summarised suction may be beneficial. Clearing the mouth purpose-designed container. in the ‘ABCDE’ approach (Table 3). should be done with great care with a ‘finger The intravenous route for emergency Ensure that the environment is safe. It is sweep’ in adults to avoid pushing material drugs is no longer recommended for dental important to call for help at an early stage further into the upper airway.3 Simple practitioners. Formulations have now been – this includes anything developed that allow other routes to be used. from other members of the These are quicker and user-friendly. Oxygen dental team to calling for an must always be available in a format that ambulance with paramedic allows delivery at flow rates up to 15 litres support. A continuous per minute. reappraisal of the patient’s condition should be carried EQUIPMENT AND TRAINING out. The airway must always The Resuscitation Council (UK) has be the starting point for recommended the equipment shown in this. Without a functioning, Table 22 as the minimum that should be oxygenated airway, all other available. Named individuals should be management steps are futile. nominated to check equipment. This should It is important to assess be carried out at least weekly and audited. the success or otherwise of It is a public expectation that automated manoeuvres or treatments external defibrillators (AEDs) should be given, remembering that available in the healthcare environment and some therapies may take time Fig. 1 The ‘head tilt, chin lift’ Fig. 2 The ‘jaw thrust’ dentistry is not considered an exception.2 to work. manoeuvre for opening up manoeuvre for opening up the the airway airway. Avoids neck extension www.nature.com/BDJTeam BDJ Team 12 © 2014 Macmillan Publishers Limited. All rights reserved ARTICLE Table 4 Signs of airway obstruction Inability to complete sentences or speak ‘Paradoxical’ movement of chest and abdomen (‘see-saw’ respiration) Use of accessory muscles of respiration Blue lips and tongue (central cyanosis) No breathing sounds (complete airway obstruction) Stridor (inspiratory) – obstruction of larynx or above Wheeze (expiratory) – obstruction of lower airways for example, asthma or chronic obstructive pulmonary disease Gurgling – suggests liquid or semi-solid material in the upper airway Fig. 3 Different sizes of Guedel oro-pharyngeal airways – Snoring – the pharynx is partly occluded by the soft palate or tongue to be used in the unconscious patient adjuncts, such as oropharyngeal airways ■ This should be done for no more than ten straight arms the sternum should be (Fig. 3) may be used. An impaired airway seconds to determine normal breathing depressed 4-5 cm may be recognised by some of the signs and ■ If there is any doubt as to whether breathing ● After each compression all the pressure symptoms summarised in Table 4. is normal, action should be as if it is not should be released so that the rib cage It is important to administer oxygen at high normal that is, to CPR. recoils to its rest position but the hands concentration (15 litres per minute) via a should be maintained in contact with well-fitting face mask with a port for oxygen Agonal gasps refer to abnormal breathing the sternum (Fig. 4) and a rebreathe mask. Even patients present in up to 40% of victims of cardiac ● The rate should be approximately 100 with chronic obstructive pulmonary disease arrest. CPR should therefore be carried out if times per minute (a little less than two who may retain carbon dioxide should be given the victim is unconscious (unresponsive) and compressions per second) a high concentration of oxygen. Such patients not breathing normally. Agonal gasps should ● After 30 compressions the airway should may depend on hypoxic drive to stimulate not delay the start of CPR as they are not be opened using head tilt and chin lift respiration but in the short-term a high normal breathing. and two rescue breaths should be given. concentration of oxygen will do no harm. This may be carried out using a bag If the unconscious patient is breathing normally and mask or mouth-to-mouth (with Breathing (B) and circulation (C) the patient should: the nostrils closed between thumb and Look, listen and feel for signs of respiratory Be turned into the recovery position (essentially index finger) or mouth-to-mask distress. This should be done while keeping on their side – best learnt as a practical exercise) ■ Practical skills are best learnt on a the airway open and the clinician should: ■ Send for help or call for an ambulance resuscitation course but certain principles ■ Look for chest movement ■ Ensure that breathing continues.

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