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PRACTICE
drugs used.
• Recognises signs and symptoms of
In this paper, the actions needed to manage specific medical emergencies are discussed. Each emergency requires a correct
diagnosis to be made for effective and safe management. Contemporary management in dental practice avoids the
intravenous route when drugs are required to treat the emergency.
INTRODUCTION be seen in dental practice. It results in loss Table 1 Summary of medical emergencies
The basic principles discussed in the previous of consciousness as a result of inadequate that may be encountered in dental practice
paper1 in this series should be applied cerebral perfusion. It is essentially a reflex, Vasovagal syncope (faint)
to all medical emergency situations. The which is mediated by autonomic nerves,
Hyperventilation/’panic attack’
cornerstone of emergency management is leading to widespread vasodilatation in
the ABCDE approach (Airway, Breathing, the splanchnic and skeletal vessels and Acute asthma attack
Circulation, Disability, Exposure). Emergencies bradycardia, resulting in diminished cerebral
Angina/myocardial infarction
can usually be anticipated by obtaining a perfusion. Fainting can be precipitated by
thorough medical history.2 Once the nature pain or emotional stress, changes in posture Epileptic seizures
of the emergency has been established, more or hypoxia. Some patients are more prone
Diabetic emergencies
specific management must be instituted, to fainting than others and it is wise to treat
underpinned by the ABCDE approach. fainting-prone patients (established from Allergies/hypersensitivity reactions
Examples of medical emergencies that can the history or previous experience) in the
Choking and aspiration
arise in dental practice are listed in Table 1. The supine position.
diagnosis and management of specific medical A similar clinical picture may be seen in Adrenal insufficiency
emergencies is discussed below. ‘carotid sinus syndrome’. Mild pressure on
Cardiac arrest
the neck in such patients (usually the elderly)
VASOVAGAL SYNCOPE leads to a vagal reaction producing syncope.
(SIMPLE FAINT) This situation may progress to bradycardia or exposure to an allergen. It is important to
Vasovagal syncope or the simple faint is or even cardiac arrest. gain some idea of the severity of attacks from
the most common medical emergency to the history. It is vital to gather information
Signs and symptoms - fainting related to precipitating factors, effectiveness
• Patient feels faint/light headed/dizzy of medication, hospital admissions due to
GENERAL MEDICINE • Pallor, sweating asthma and the use of systemic steroids.
1. History taking and examination of the • Pulse rate slows It is important that asthmatic patients
clothed patient • Low blood pressure bring their usual inhaler(s) with them – if the
2. The drug box, equipment and basic principles • Nausea and/or vomiting inhaler has not been brought it must be in the
of management
• Loss of consciousness. emergency kit or treatment should be deferred.
3. Management of specific medical
emergencies in dental practice
If the asthma is in a particularly severe phase
Treatment of fainting elective treatment may be best postponed.
4. Infections and infection control
• Lie the patient flat and raise the legs – Drugs that may be prescribed by dental
5. Immunological disease and dental practice
This paper will be included in a new third edition of A clinical
recovery will normally be rapid practitioners, particularly non-steroidal anti-
guide to general medicine and surgery, to be published by BDJ • A patent airway must be maintained inflammatory drugs (NSAIDs), may worsen
Books in autumn 2014.
• If recovery is delayed, oxygen (15 litres asthma and are therefore best avoided.
per minute) should be administered and
1
Consultant/Honorary Clinical Professor, 2Senior Lec‑
other causes of loss of consciousness be Use of inhalers in patients
turer/Honorary Consultant, School of Dental Sciences,
Newcastle University, Framlington Place, Newcastle considered. with asthma
upon Tyne, NE2 4BW
*Correspondence to: Mark Greenwood ASTHMA Inhalers
Email: Mark.Greenwood@ncl.ac.uk
Asthma is a potentially life-threatening Even if an inhaler is used properly around
Refereed Paper condition and should always be taken 50% of aerosol will be deposited in the
Accepted 7 November 2013
DOI: 10.1038/sj.bdj.2014.549 seriously. 3 An asthma attack may be mouth and only 10% reach the airways
© British Dental Journal 2014; 217: 21-26 precipitated by exertion, anxiety, infection below the larynx.
• Most asthma attacks will respond to • If no paper bag is handy, the patient’s First fit
the patient’s own inhaler, for example cupped hands could be an alternative.
Difficulty in monitoring the patient’s condition
salbutamol (may need to repeat after
2‑3 minutes) Hyperventilation leads to carbon dioxide
• If no rapid response, or features of being ‘washed out’ of the body, producing angina they should have brought this with
severe asthma, call an ambulance an alkalosis. If hyperventilation persists, them or it should be readily to hand in the
• A medical assessment should be arranged carpal (hand) and pedal (foot) spasm (tetany) emergency kit. Similarly, it is important to
for patients who require additional doses may be seen (Fig. 1). Rebreathing exhaled check that the patient has taken their normal
of bronchodilator to end an attack air helps to return the situation to normal medication on the day of their appointment.
• A spacer device may need to be used if relatively quickly. Classically, the pain of angina is described
patient has difficulty using the inhaler as a ‘crushing’ or ‘band-like’ tightness of
• If the patient is distressed or shows any CHEST PAIN the chest, which may radiate to the left arm
of the signs of life-threatening asthma, Most patients who experience chest pain from or mandible. There are many variations,
urgent transport to hospital should be a cardiac origin in the dental surgery are likely however. The pain of myocardial infarction
arranged to have a previous history of cardiac disease. (MI) will often be similar to that of angina
• Fifteen litres per minute of oxygen If a patient uses medication to control known but more severe and, unlike angina, will
not be relieved by glyceryl trinitrate (GTN). • A patient who has had surgical dental is now licenced for use.7
In cases of angina, the patient should treatment should be highlighted to the • For children (Epistatus®):
use their GTN spray, which will usually ambulance crew as any significant risk - Child 1‑5 years, 5 mg
remove the symptoms. Dental treatment of haemorrhage may affect the decision - Child 5‑10 years, 7.5 mg
may be best left until another day if there to use thrombolytic therapy - Child over 10 years, 10 mg
is an attack, according to the practitioner’s • If the patient becomes unresponsive, the • The parents of some children with poorly
discretion. More severe chest pain always practitioner should check for ‘signs of life’ controlled epilepsy will carry rectal
warrants postponement of treatment and an (breathing and circulation) and start CPR. diazepam. As part of pre-treatment
ambulance should be called. preparation, it is wise to arrange with
Features that make chest pain unlikely to EPILEPTIC SEIZURES the parent for them to be on hand to
be cardiac in origin are: pains that last less The history will usually reveal the fact that a administer this should a seizure occur
than 30 seconds, however severe, stabbing patient has epilepsy.2 A history should obtain • In the absence of rapid response to
pains, well-localised left submammary pain information with regard to the nature of treatment, call an ambulance.
and pains that continually vary in location. any seizures, their frequency and degree of
Chest pain that improves on stopping control. The type and efficacy of medication Criteria for sending a patient with
exertion is more likely to be cardiac in origin should be determined. Signs and symptoms epilepsy to hospital after a seizure have
than one that is not related. Pleuritic pain is vary considerably. been developed by the National Institute
sharp in character, well localised and worse for Health and Care Excellence and are
on inspiration. Signs and symptoms - epilepsy summarised in Table 3.
Oesophagitis can produce a retrosternal • The patient may have an ‘aura’ that a
pain that worsens on bending or lying down. seizure is about to occur DIABETIC EMERGENCIES
A complicating factor in differentiation from • Tonic phase – loss of consciousness, The history should be used to assess the degree
cardiac chest pain is that GTN, due to its patient becomes rigid and falls and of diabetic control achieved by the patient. A
action on the muscle of the oesophagus, may becomes cyanosed history of recurrent hypoglycaemic episodes
ease the pain. • Clonic phase – jerking movements of the and markedly varying blood glucose levels
Musculoskeletal pain will often be limbs, tongue may be bitten (from the patient’s measurements) suggest
accompanied by tenderness to palpation • Frothing at the mouth, urinary that a patient attending for dental treatment
in the affected region or on movement. As incontinence is more likely to develop hypoglycaemia. It
mentioned earlier, hyperventilation may • The seizure often gradually abates after is wise to treat diabetic patients early in the
produce chest pain. A list of possible causes a few minutes. The patient may remain day and ensure that they have had their
of chest pain is given in Table 2. unconscious. They may remain confused normal medication and something to eat
It is clearly important to exclude angina after consciousness has been regained before attending.
and myocardial infarction in the patient • Hypoglycaemia may present as a fit A dentist in general practice is much more
complaining of chest pain.5,6 If in doubt, and should be considered (including likely to encounter hypoglycaemia than
treat as cardiac pain until proven otherwise. in epileptic patients) – blood glucose hyperglycaemia since the latter has a much
measurement at an early stage is slower onset. It should be remembered that
Signs and symptoms – therefore wise. diabetic control may be adversely affected
myocardial infarction by oral sepsis, leading to an increased risk
• Severe, crushing chest pain which may In patients with a marked bradycardia of complications.8
radiate to the shoulders and down the (pulse rate less than 40 beats per minute) the
arms (particularly the left arm) and into blood pressure may drop to such an extent Signs and symptoms
the mandible that it causes transient cerebral hypoxia - hypoglycaemia
• The skin becomes pale and clammy leading to a brief fit. This is not a true fit • Trembling
• Shortness of breath and represents a vasovagal episode. • Hunger
• Pulse becomes weak and patient may • Headache
become hypotensive Treatment of an epileptic seizure • Sweating
• Often there will be nausea and vomiting The decision to give medication should be • Slurring of speech
• Not all patients fit this picture. made if seizures are prolonged (with active • ‘Pins and needles’ in lips and tongue
convulsions for 5 minutes or more [status • Aggression and/or confusion
Treatment of myocardial infarction epilepticus] or seizures occurring in quick • Seizures
• The practitioner should remain calm and succession). If possible, high flow oxygen • Unconsciousness.
reassuring should be administered. The possibility of
• Call 999 immediately the patient’s airway becoming occluded Treatment of hypoglycaemia
• Most patients will be best managed in should be constantly remembered and the • Lay the patient flat (remember A, B, C)
the sitting position but patients who feel airway must therefore be protected. • If the patient is conscious, give
faint should be laid flat • As far as possible, ensure safety of the 10‑20 g oral glucose (3 lumps of sugar,
• Administer high flow oxygen (15 litres patient and practitioner (do not attempt 2‑4 teaspoons of sugar or 100 ml of
per minute) to restrain) a sugary drink such as Coca Cola) or
• Give sublingual GTN spray • Midazolam given via the buccal or GlucoGel® (Fig. 3)
• Give 300 mg aspirin orally to be chewed intranasal route (10 mg for adults). • If the patient is unconscious give
(if no allergy) – ensure that when The buccal preparation is marketed 1 mg glucagon intramuscularly (or
handing over to the receiving ambulance as ‘Epistatus®’ (10 mg/ml), (Fig. 2). A subcutaneously)
crew that they are made aware of this paediatric formulation, Buccolam® (5 ml) • Get medical help.
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