Medical Emergencies And Resuscitation In Dental Practice

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					Medical Emergencies And
Resuscitation In Dental Practice

   Ziad Malkawi
   DDS, MSc, Max.Fac.S.Cert, FFDRCSI
   Faculty Of Dentistry
   University Of Jordan

Be Prepared
- Surgery
 Drugs
 Equipment
- Staff
 CPR training
 Obtaining help
- Patients

   Medical history
   Drug history

Emergencies that might occur:
- Loss of consciousness
   Faint
   Cardiac arrest
   Hypoglycemia
   Cerebrovascular accident
   drugs
- Breathing difficulties
 Asthma
 Heart failure
 Anaphylaxis
 hysteria
- Choking
 Inhaled foreign body
 Laryngeal oedema
 -   Fitting

 Epilepsy
 Hypoglycemia
 Cardiac arrest

- Assessment
   Responsiveness
   Airway
   Breathing
   Circulation
- First aid treatment
- Obtaining help
- Definitive treatment
                                  Appendix A

         1.   Drugs to be available in very dental practice
 (i)                     Oxygen
 (ii)            Adrenaline 1 mg in 1m           x            5 ampoules
(iii)                Lignocaine 1%              1ml           5 ampoules
(iv)                 Atropine O.6mg            1ml x          5 ampoules
 (v)             Calcium Chloride 10 %         10ml           2 ampoules
(vi)            Sodium Bicarbonate 8.4 %       50ml           3 ampoules
(vii)      Glycery Trinitrate Tabs 300mcg        x                10
          or Glyceryl Trinitrate 400mcg per
           metered dose sub-lingual spray        x                1
(viii)            Aminophylline 250mg          10ml           2 ampoules

(ix)          Salbutamol inhaler 100mcg per
                      metered dose               x             2 refills
 (x)      Chlorpheniramine maleate 10mg        1ml x          2 ampoules
(xi)                 Dextrose 50%              50ml               1
(xiv)                  Infusion solution
                       (a) Dextrose 4% saline                      500ml
                             0.18%                                 x
                       (b) Colloid solution                        500ml

2.     Drugs to be available in dental practices providing intravenous sedation.

(i)                    Flumazenil 500mcg                             5ml x        5 ampoules

(ii)                   Naloxone 0.4mg

3.     Drugs to be available in dental practices providing general anaesthesia.

(i)                    Suxamethonium 100mg                         2ml x          5 ampoules
                                                                               Appendix B
     List Of Essentlal Items Of Equipment For Esuscitation Which
              Must Be Available In Every Dental Practice

1.  Suction apparatus – powered and portable ( independently powered).
2.     Simple airway adjunct (e.g. pocket resuscitator mask with valve).
3.     Cricothyroid puncture needle                   x         1

Oxygen and Artificial Ventilation
1.    Portable oxygen with appropriate valves, metering and delivery system
2.    Self-inflating bag, valve and mask with oxygen enhancement facility.

Maintenance of Circulation

1.     Disposable syringes – sizes 2, 5, 10ml        x          5    of each
2.     Disposable needles – sizes 21 & 23g           x          10   of each
3.     Disposable IV vannulae – sizes 16 & 22g       x          5    of each
4.     Disposable IV Infusion Sets                   x          2
5.     Scissors                                      x          1
6.     Tourniquet, Sphygmomanometer, Stethoscope     x          1    of EACH
7.     Injection Swabs
     Medical Emergencies And

- Features
 Reflex response that occurs in the conscious individual.
 Consciousness lost if systolic BP falls below 60mmHg.
 Effects aggravated by starvation, pain or stuffy
- Diagnosis
   Light headed +/- nausea
   Pale and unwell
   Cold sweaty hands
   Thready pulse, low BP
   Unresponsive
Medical Emergencies And

   - Management of faint:
    Lie flat, elevate legs
    Recovery position
    Maintain airway, check
     breathing and pulse
    Postpone treatment.
Medical Emergencies And

 Heart Attack
-   Diagnosis
   Previous history
   Retrosternal chest pain that might radiate
   Pale and unwell
   Cold and sweaty
-   Management
 Reassure and sit down
 GTN under tongue
 Check pulse and BP
 Angina is self-limiting if pain or symptoms persist
  suspect MI
 Oxygen by face mask
 Rapid transfer to hospital by ambulance.
Medical Emergencies And

   -   Features
    bronchospasm may occur in acute asthma, acute
     or chronic bronchitis or in anaphylaxis.
   -   Diagnosis
      History of asthma
      Breathing difficulty especially breathing out.
      Audible wheeze
      Sweaty, tachycardia, cyanosis.
   - Management
    Reassure
      Sit up
      Salbutamol inhaler
      Oxygen by face mask
      Arrange transfer to hospital.
Medical Emergencies And
Diabetic coma (hypoglycaemia)
- Features
 Diabetics on insulin or oral hypoglycaemics
  may drop their blood sugar if they take their
  medication and do not eat.
 Presence of oral sepsis may make control of
  diabetes difficult
 Use of synthetic human insulin.
- Diagnosis
 History
 confusional aggression
 Pale and sweaty
 Rapid, thready pulse
 Unresponsive
Medical Emergencies And
- Diabetic coma (hypoglycaemia)
- Management
 Oral glucose if able to swallow
 If unresponsive may need to give IV 50%
  dextrose or IM or SC glucagon.
 If delayed response or unwell arrange transfer
  to hospital
        Medical Emergencies And
Anaphylactic shock
- Features
 Allergy to an administered antigen (usually a
  drug or food ) causes histamine release from
  mast cells resulting in vasodilatation, increased
  capillary permeability and bronchospasm
 Uncommon with local anaesthetic agents, more
  common with antibiotics or anaesthetic agents
- Diagnosis
   Rash and oedema
   Tachycardia
   Hypotension
   Bronchospasm
   Cardiopulmonary arrest
Medical Emergencies And
Anaphylactic shock:
- Management
 If mild symptoms, reassure, sit down,
  check pulse and BP. IV access if possible
 adrenaline 1:1000 0.5ml SC, IM
 Hydrocortisone 200mg IM/IV
 If bronchospasm give oxygen by face mask
 If collapse check ABC
 Arrange transfer to hospital
Medical Emergencies And
Cerebrovascular accident
- Features
 An ischaemic episode in the brain caused by
  vascular spasm, a clot or a bleed
 Symptoms may last only a short time and a
  complete recovery is made. This is a transient
  ischaemic attack
 If symptoms are prolonged and neurological
  impairment persists it is a completed stroke
Medical Emergencies And
 Cerebrovascular accident
- Diagnosis
 Varied symptoms
 Slurred speech
 Weakness of arms or legs, often one-sided
 Visual problems
 Confusion, aggressive behaviour
 Unrousable
- Management
 If unrousable put in recovery position, maintain airway,
  check breathing and pulse
 Arrange transfer to hospital
Medical Emergencies And
- Features
 on medication and a fit is precipitated by extreme
    anxiety, starvation or omission of medication
    prior to treatment
- Diagnosis
 Aura
 Colonic tonic contractions
 Loss of consciousness
- Management
 Protect from injury
 Maintain airway
 If rapid recovery, arrange escort and transport
 If not known to be epileptic or in status
    epilepticus arrange transfer to hospital
Medical Emergencies And
Upper airway obstruction
-   Causes
•   Inhaled foreign body
•   Laryngeal edema due to infection, trauma or anaphylaxis.
-   Diagnosis
   No symptoms
   Coughing and gagging
   Spasm of vocal cords giving strider and even respiratory arrest
   Bronchospasm
-   Management
   If asymptomatic check mouth and faucets carefully; postpone
    treatment; escort for chest X-ray; may require endoscopy of gut
    or bronchoscopy for lungs
   If symptoms of upper airway obstruction; encourage coughing;
    back blows; heimlich’s abdominal thrust; cricothyrodotomy.