Medical Emergencies And Resuscitation In Dental Practice Ziad Malkawi DDS, MSc, Max.Fac.S.Cert, FFDRCSI Faculty Of Dentistry University Of Jordan MEDICAL EMERGENCIES AND RESUSCITATION Be Prepared - Surgery Drugs Equipment - Staff CPR training Obtaining help - Patients Medical history Drug history Allergies Instructions communication MEDICAL EMERGENCIES AND RESUSCITATION 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 MEDICAL EMERGENCIES AND RESUSCITATION Management - Assessment Responsiveness Airway Breathing Circulation - First aid treatment - Obtaining help - Definitive treatment Appendix A LIST OF DRUGS FOR EMERGENCY USE Minimum 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 x (iv) Atropine O.6mg 1ml x 5 ampoules (v) Calcium Chloride 10 % 10ml 2 ampoules x (vi) Sodium Bicarbonate 8.4 % 50ml 3 ampoules x (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 x (ix) Salbutamol inhaler 100mcg per metered dose x 2 refills (x) Chlorpheniramine maleate 10mg 1ml x 2 ampoules (xi) Dextrose 50% 50ml 1 x (xiv) Infusion solution (a) Dextrose 4% saline 500ml 0.18% x (b) Colloid solution 500ml x 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 AIRWAY MAINTENANCE 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 Resuscitation Faint - Features Reflex response that occurs in the conscious individual. Consciousness lost if systolic BP falls below 60mmHg. Effects aggravated by starvation, pain or stuffy environment. - Diagnosis Light headed +/- nausea Pale and unwell Cold sweaty hands Thready pulse, low BP Unresponsive Medical Emergencies And Resuscitation - Management of faint: Lie flat, elevate legs Recovery position Maintain airway, check breathing and pulse Postpone treatment. Medical Emergencies And Resuscitation 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 Resuscitation Asthma - 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 Resuscitation 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 Resuscitation - 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 Resuscitation 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 Resuscitation 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 Resuscitation 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 Resuscitation 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 Resuscitation Epilepsy - 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 home If not known to be epileptic or in status epilepticus arrange transfer to hospital Medical Emergencies And Resuscitation 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.