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key words learning objectives author medical emergencies dental risk identify the most common medical mark greenwood bds mds assessment management oral surgery emergency scenarios that the phd fdsrcs mb chb ...

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                KEY WORDS                                        LEARNING OBJECTIVES                              AUTHOR
                Medical emergencies, Dental, Risk                •	Identify	the	most	common	medical	              Mark Greenwood BDS, MDS,  
                assessment, Management, Oral Surgery               emergency	scenarios	that	the	                  PhD, FDSRCS, MB ChB, FRCS, FHEA
                                                                   dental	team	may	face                           Consultant	in	Oral	and	Maxillofacial	Surgery,	
                                                                 •	Understand	how	to	assess	the	                  Newcastle	University	School	of	Dental	Sciences
                                                                   risk	of	medical	events	occurring
                                                                 •	Be	confident	in	the	basic	management	
                                                                   of	common	medical	emergencies
                                                                           MARK GREENWOOD
                                                                           Prim Dent J. 2018;7(3):46-56
                                                                        MEDICAL EMERGENCIES:  
                     RISK ASSESSMENT AND MANAGEMENT
                                                                 ABSTRACT
                                                                 Dental practitioners need to have knowledge of the risk assessment, diagnosis 
                                                                 and management of medical emergencies. This paper deals with risk assessment 
                                                                 and basic management principles, applicable to all emergencies. More specific 
                                                                 aspects of medical emergency management are also discussed.
                         edical emergencies in dental        should always be made to ensure that the          patient. It is important to call for help at  
                         practice are not common             medication has been taken as usual.               an early stage. A continuous reappraisal 
                          events. However, one study         The ‘ABCDE’ approach                              of the patient’s condition should be carried 
            M from Germany has shown                                                                           out. The airway must always be the starting 
            that the incidence of medical emergencies        to the sick patient                               point for this. Without a functioning airway, 
            in the dental environment may be more            Medical emergencies can often be prevented        all other management steps are ultimately 
                                         1
            common than often thought.  All members          with early recognition. Signs such as             going to be unsuccessful. It is important 
            of the dental team need to be aware of           abnormal patient colour, breathing or pulse       to assess (and reassess) the success or 
            what their role would be in the event of a       rate can signal an impending emergency.           otherwise of manoeuvres or treatments 
            medical emergency and should be trained          A systematic approach to an acutely ill           given, remembering that some of these 
            appropriately with regular practice sessions.    patient should be adopted – the ‘ABCDE’           may take time to work.
            Risk assessment for                              approach is summarised in Table 1.
                                                                                                               If the patient is conscious, ask them 
            medical emergencies                              Always ensure that the immediate                  how they are. This can give important 
            Potential medical emergencies that               surrounding environment is safe for the           information about the problem (for 
            could arise can be highlighted by taking 
            a thorough medical history. A risk 
            assessment can be made by considering                                                              Figure 1: Oro-pharyngeal airways
            the patient’s American Society of 
            Anaesthesiologists (ASA) classification 
            category, summarised below:
            •	 ASA I: Healthy.
            •  ASA II: Mild systemic disease –  
                no functional limitation.
            •  ASA III: Severe systemic disease – 
                definite functional limitation.
            •  ASA IV: Severe disease –  
                constant threat to life.
            •  ASA V: Moribund.
            •  ASA VI: Patient being ventilated  
                for organ donation purposes.
            If medication is normally used, a check 
         46                                                                                                    PRIMARY DENTAL JOURNAL 
                                                                                                                                                                                                                                                                                                                                                                                                                         TABLE 1                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               TABLE 2
                                                                                                                                                                                                                                                                                                                                                                                                                         THE ‘ABCDE’ APPROACH TO                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               SIGNS OF AIRWAY OBSTRUCTION 
                                                                                                                                                                                                                                                                                                                                                                                                                         AN EMERGENCY PATIENT                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    • Inability to complete sentences or speak
                                                                                                                                                                                                                                                                                                                                                                                                                            A                                                                                                                                                                                    Airway                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          • ‘Paradoxical’ movement of chest and abdomen (‘see-saw’ respiration)
                                                                                                                                                                                                                                                                                                                                                                                                                            B                                                                                                                                                                                    Breathing                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       • Use of accessory muscles of respiration
                                                                                                                                                                                                                                                                                                                                                                                                                            C                                                                                                                                                                                    Circulation                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     • Blue lips and tongue (central cyanosis)
                                                                                                                                                                                                                                                                                                                                                                                                                            D                                                                                                                                                                                    Disability (or neurological                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     • No breathing sounds (complete airway obstruction)
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 status)                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         • Stridor (inspiratory) – obstruction of larynx or above
                                                                                                                                                                                                                                                                                                                                                                                                                            E                                                                                                                                                                                    Exposure (in dental practice,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   • Wheeze (expiratory) – obstruction of lower airways, e.g. asthma or chronic 
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 to facilitate placement                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           obstructive pulmonary disease
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 of AED paddles) or                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                Gurgling – suggests liquid or semi-solid material in the upper airway
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 appropriately exposing parts                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    •
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 to be examined                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  • Snoring – the pharynx is partly occluded by the soft palate or tongue
                                                                                                                                                                                                                                                                                                                                                        example, the patient who cannot speak or                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             via a well-fitting face mask with a port                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            (unresponsive) and not breathing normally. 
                                                                                                                                                                                                                                                                                                                                                        tells you that they have chest pain). If the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         for oxygen and a rebreathe mask. Even                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               Agonal gasps should not delay the start  
                                                                                                                                                                                                                                                                                                                                                        patient is unresponsive, the patient should                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          patients with chronic obstructive pulmonary                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         of CPR as it is not normal breathing.
                                                                                                                                                                                                                                                                                                                                                        be shaken and asked “Are you all right?”                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             disease (COPD) who retain carbon dioxide 
                                                                                                                                                                                                                                                                                                                                                        If they do not respond at all, have                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  should be given a high concentration                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                If the patient is breathing normally: 
                                                                                                                                                                                                                                                                                                                                                        no pulse, are not breathing properly                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 of oxygen to deal with the immediate                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                •  The patient should be turned into  
                                                                                                                                                                                                                                                                                                                                                        (occasional ‘gasps’) and show no signs                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               emergency. Such patients may depend                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    the recovery position. 
                                                                                                                                                                                                                                                                                                                                                        of life, they have had a cardiac arrest and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          on hypoxic drive to stimulate respiration,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          •  Call for further help or an ambulance.
                                                                                                                                                                                                                                                                                                                                                        should be managed as described later.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                but in the short-term a high concentration                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          •  Ensure that breathing continues.
                                                                                                                                                                                                                                                                                                                                                        They may respond in a breathless manner                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              of oxygen will do no harm.
                                                                                                                                                                                                                                                                                                                                                        and should be asked “Are you choking?”                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   If the patient is not breathing normally:
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             Breathing (B) and Circulation (C)                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   •  Ensure an ambulance is called; this 
                                                                                                                                                                                                                                                                                                                                                        Airway (A) – Assessment                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              Look, listen and feel for signs of respiratory                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         may necessitate leaving the victim, 
                                                                                                                                                                                                                                                                                                                                                        and management                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       distress. This should be done while                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    but in a dental setting the practitioner 
                                                                                                                                                                                                                                                                                                                                                        Airway obstruction is a medical emergency                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            keeping the airway open. The clinician                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 should not be working alone so the 
                                                                                                                                                                                                                                                                                                                                                        and must always be managed quickly. A                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                should:                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                situation should not arise.
                                                                                                                                                                                                                                                                                                                                                        simple method of clearing the airway is                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              •  Look for chest movement and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      •  Chest compressions should be started 
                                                                                                                                                                                                                                                                                                                                                        usually all that is needed. A head tilt, chin lift                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     symmetry of such movement.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           with the patient in the fully supine 
                                                                                                                                                                                                                                                                                                                                                        or jaw thrust will open the airway. Patients                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         •  Listen for breath sounds (at the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    position on a firm surface:
                                                                                                                                                                                                                                                                                                                                                        who are suddenly unable to speak are in                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                patient’s mouth).                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    -   Kneel/stand at the side of the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
                                                                                                                                                                                                                                                                                                                                                        real danger. Establishing a patent airway is                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                         •  Feel for air on the rescuer’s cheek,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     patient.
                                                                                                                                                                                                                                                                                                                                                        critical. It is important to remove any visible                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        with the rescuer’s head turned against                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               -   Place the heel of one hand in the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  
                                                                                                                                                                                                                                                                                                                                                        foreign bodies, blood or debris and the use                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            the patient’s mouth.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      centre of the patient’s chest and the  
                                                                                                                                                                                                                                                                                                                                                        of suction may be beneficial. Clearing the                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           •  This should be done for no more                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          other hand on top of the first hand  
                                                                                                                                                                                                                                                                                                                                                        mouth should be done with great care with                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              than 10 seconds to determine normal                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                       – it will usually be possible to do  
                                                                                                                                                                                                                                                                                                                                                        a “finger sweep” in adults, under direct                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               breathing.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                this without removing the patient’s  
                                                                                                                                                                                                                                                                                                                                                        vision, to avoid pushing material further                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            •  If there is any doubt as to whether                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      clothes. If there is any doubt, outer  
                                                                                                                                                                                                                                                                                                                                                        into the upper airway. Blind finger sweeps                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             breathing is normal, action should                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                        clothing should be undone/removed.
                                                                                                                                                                                                                                                                                                                                                        should not be carried out. Simple adjuncts,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            be as if it is not normal, that is,                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  -   Interlock the fingers of both hands                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          
                                                                                                                                                                                                                                                                                                                                                        such as oropharyngeal airways (see Figure                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              to commence cardiopulmonary                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                               avoiding pressure over the ribs,  
                                                                                                                                                                                                                                                                                                                                                        1) may be used. An impaired airway may                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 resuscitation (CPR).                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      upper abdomen or the lower end  
                                                                                                                                                                                                                                                                                                                                                        be recognised by some of the signs and                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           of the sternum.
                                                                                                                                                                                                                                                                                                                                                        symptoms given in Table 2.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           The term ‘agonal gasps’ refers to abnormal                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             -   The clinician should be positioned                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                             breathing, present in up to 40% of victims                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                  vertically above the patient’s chest.  
                                                                                                                                                                                                                                                                                                                                                        It is important to administer oxygen at                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              of cardiac arrest. CPR should therefore                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                     With straight arms the sternum  
                                                                                                                                                                                                                                                                                                                                                        high concentration (15 litres per minute)                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            be carried out if the victim is unconscious                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                 should be depressed 4-5cm. 
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                MEDICAL EMERGENCIES:  
                RISK ASSESSMENT AND MANAGEMENT
               FIGURE 2                                                                                       Figure 3:  
               ALGORITHM FOR BASIC                                                                            A glucometer
               LIFE SUPPORT IN AN                                                                              In children (before puberty), five initial 
               ADULT PATIENT                                                                                   ventilations should be carried out 
                                                                                                               and thereafter 15 compressions in an 
                UNRESPONSIVE?                                                                                  ongoing ratio of two ventilations to 15 
                                                                                                               compressions. 
                Shout for help
                                    NOT BREATHING                                                              Circulation (C)
                Open airway           NORMALLY?                                                                Circulatory assessment should never delay 
                                                                                                               the start of CPR. Simple observations to 
                                                                                                               make a gross assessment of circulatory 
                                          Call 999                                                             efficiency are given in Table 3. By far 
                                                                                                               the most common cause of a collapse 
                               30 chest compressions                                                           that is essentially circulatory in origin is 
                                                                                                               the simple faint (vaso-vagal syncope). A 
                                    2 rescue breaths                                                           rapid recovery can be expected in these 
                                    30 compressions                                                            cases if the patient is laid flat and the legs 
                                                                                                               raised. Prompt management is required 
                                                                                                               as cerebral hypoxia has devastating 
                                                                                                               consequences if prolonged. Causes other 
                -    After each compression all the              qualified help takes over or the rescuer      than a faint must be considered if recovery 
                     pressure should be released so that         becomes exhausted.                            does not happen quickly.
                     the rib cage recoils to its rest  
                     position but the hands should           If rescue breaths do not make the chest rise:     Checking the carotid pulse to diagnose 
                     be maintained in contact with           •  Check for visible obstruction(s) in the        cardiac arrest can be unreliable, 
                     the sternum.                                mouth and remove it/them if possible.         even when attempted by health care 
                                                                                                                             2
                -    The rate should be approximately        •  Make sure that the head tilt and chin          professionals.  Checking the carotid 
                     100 times per minute (a little less         lift are adequate.                            pulse should only be carried out by 
                     than two compressions per second).      •  Do not waste time attempting more              those proficient in doing this. The latest 
                                                                                                                         3
            •  After 30 compressions, the airway                 than two breaths each cycle before            guidelines  highlight the need to identify 
                should be opened using head tilt and             continuing chest compressions.                agonal gasps (as well as the absence of 
                chin lift and two rescue breaths should                                                        breathing) as a sign to commence CPR  
                be given. This may be carried out using      Carrying out these manoeuvres is tiring,          and lay no particular emphasis on 
                a bag and mask or mouth-to-mouth             and if there is more than one rescuer, CPR        checking the carotid pulse.
                (with the nostrils closed between thumb      should be alternated between them every 
                and index finger) or mouth-to-mask.          two minutes. The algorithm for adult basic        Disability (D)
            •  Practical skills are best learnt on           life support is given in Figure 2.                The term disability refers to an assessment 
                a resuscitation course but certain 
                principles are given below:
                -   Inflations should make the chest            TABLE 3
                    rise. About one second should               SIMPLE METHODS OF CIRCULATORY ASSESSMENT
                    be taken to do this.
                -   The chest should be allowed to fall         Signs          •	Are the patient’s hands blue or pink, cool or warm?
                      while maintaining the airway; two                        •	What is the capillary refill time?* 
                    rescue breaths should be given.
                -   Hands should be returned to the                            •	Pulse rate (carotid or radial artery), rhythm and strength
                    sternum without delay to continue           Symptoms       •	Is there a history of chest pain/does the patient report chest pain? 
                    the chest compressions in a ratio                           
                    of 30:2.                                                   *If pressure is applied to the finger nail to produce blanching, the colour should  
            •  Only stop to recheck the patient if                             return in less than 2 seconds in a normal patient. Remember that local causes  
                normal breathing starts, otherwise                             such as a cold environment could also delay the response
                resuscitation should be continued until 
         48                                                                                                    PRIMARY DENTAL JOURNAL 
                                                                  TABLE 5
                                                                  CONTENTS OF THE EMERGENCY DRUG BOX  
                                                                  AND ROUTES OF ADMINISTRATION
                                                                  Drug                                                               Route of administration
                                                                  •	Oxygen (15 litres/min)                                           Inhalation
             of the neurological status of the                    •	Glyceryl trinitrate (GTN) spray (400μg per actuation)            Sublingual
             patient. Primarily it refers to the level of         •	Dispersible aspirin (300mg)                                      Oral (chewed)
             consciousness (in trauma patients a more             •	Salbutamol aerosol inhaler (100μg per actuation)                 Inhalation
             widespread neurological examination                  •	Adrenaline injection (1:1000, 1mg/ml)                            Intramuscular
             is required). Hypoxia or hypercapnia 
             (increased blood levels of carbon dioxide)           •	Glucagon injection (1mg)                                         Intramuscular/subcutaneous
             are possible causes, together with certain           •	Oral glucose solution/gel (GlucoGel®)*                             Oral
             sedative or analgesic drugs. 
                                                                  •	Midazolam 10mg or 5mg/ml (buccal or intranasal)                    Infiltration/inhalation
             It is important to exclude hypoxia or 
             hypotension as a cause for any alternation           *Alternatives: 2 teaspoons of sugar/3 sugar lumps: 
             in conscious level. Attention to the airway,                       200ml milk
             giving supplemental oxygen and supporting                          Non-diet Lucozade® 50ml
             the patient’s circulation (by lying them supine                    Coca-cola® non-diet 90ml
             and raising their legs) will in many cases                         If necessary this can be repeated at 10-15 minutes
             solve the problem. All unconscious patients 
             who are breathing and have a pulse should 
             be placed in the recovery position if they        some of the patient’s clothes, for example         is a way to increase the number of 
             are unable to protect their own airway.           to allow the application of defibrillator          compressions but is only effective for 
                                                               paddles (in dental practice), or if the            a period of about five minutes due to 
             A rapid assessment can be made of a               patient has been involved in a traumatic           reducing arterial oxygen content over 
             patient’s level of consciousness using the        incident for examination purposes (usually         time. For this reason, the technique is not 
             AVPU method:                                      in hospital). It is important to bear in           recommended for healthcare professionals. 
             •  Are they Alert?                                mind the patient’s dignity as well as the 
             •  Do they respond to Vocal stimuli?              potential for clinically significant heat loss.    The emergency drug box
             •  Do they respond to Painful stimuli?            Cardiac arrest can occur as a result of            Patients should only undergo dental 
             •  Are they Unresponsive?                         several causes. These are summarised               treatment in situations where appropriate 
                                                               in Table 4.                                        emergency equipment and in-date 
             A lapse into unconsciousness may be due                                                              emergency drugs are available. A minimum 
             to hypoglycaemia – if the blood glucose           Interruptions to chest compression in              list of drugs to be included in the emergency 
             level is less than 4mmol/litre when checked       resuscitation are common and are                   drug box are summarised in Table 5. The 
             by a glucose measuring device (see Figure         associated with a reduced chance of                list is based on that recommended by the 
                                                                        4
             3) then glucagon should be injected by the        survival.  Chest compression-only CPR              Resuscitation Council (UK). 
             subcutaneous or intramuscular route. 
             Exposure (E)
             Exposure means the appropriate and 
             proportionate loosening or removal of 
               TABLE 4
               POSSIBLE CAUSES  
               OF CARDIAC ARREST
               • Arrhythmia (most common type 
                  ventricular fibrillation or VF)                 Figure 4: A glucagon kit 
               • Myocardial infarction                            with water for dilution 
                  (may lead to an arrhythmia)                     already drawn up and 
               • Choking                                          powder for reconstitution. 
               • Bleeding                                         Kits such as these can save 
               • Drug overdose                                    valuable time in managing 
                                                                  emergencies, in this case 
               • Hypoxia                                          hypoglycaemia
             VOL. 7 NO. 3 AUTUMN 2018                                                                                                                            49
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