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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.
VOL. 7 NO. 3 AUTUMN 2018 47
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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