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CTOC16 6/29/06 18:01 Page 381
Medical emergencies and their management
16
L. Longman and C. Balmer
Introduction ■ The equipment and drugs conform to contemporane-
ous standards recommended by respected bodies.
Medical emergencies by their very nature can occur at ■ All equipment is well maintained and all drugs are
any time, without warning and not necessarily in the checked regularly and replaced prior to their expiry
clinical environment. It is therefore essential to be able to date.
recognise the nature of an emergency as soon as it occurs ■ They are trained regularly in the use of the above.
and to have the knowledge, proficiency and confidence ■ Regular ‘in-practice’ simulation of the management
to be able to undertake the appropriate remedial action. of medical problems including the preparation and
administration of emergency drugs. This is in addition
Management considerations to training in cardiopulmonary resuscitation (CPR).
Regular in-housetraining in CPR is mandatory for the
Therapists and hygienists treat patients of all ages and dental team. These sessions can be easily modified to
it is inevitable that some of these patients will have include a rehearsal of managing other acute conditions
significant medical conditions and take medication, both that do not necessarily need to progress to a cardiorespir-
of which may necessitate a modification to dental treat- atory arrest, although this remains a possible outcome.
ment. In addition many patients will experience anxiety Several scenarios can be devised around an unwell pati-
associated with their treatment. It is to be expected that ent who has the potential progressively to deteriorate,
acute medical conditions will occur in a dental practice, such as a patient with angina who may develop severe
albeit rarely. It is worth remembering that friends or fam- chest pains or a patient who experiences breathing
ily who often accompany patients, other visitors to the problems following the administration of amoxicillin.
practice and staff may become unwell and require urgent Regular rehearsal identifies problems that can then be
attention. Medical emergencies can therefore occur any- rectified in a non-judgemental and constructive manner.
where on the premises, not just in the surgery. It is essen- Simulation training undertaken in a familiar working
tial that all dental healthcare workers should have the environment allows staff clearly to understand their
knowledge and skills to recognise and provide appropri- role and the role of other members of the team, so help-
ate immediate medical care for emergencies that might ing to reduce confusion and panic when faced with a real
present in dental practice. In some instances this will emergency.
require the provision of life-saving measures prior to the It is also important for members of the team to be
arrival of specialist help. cognisant with the different methods of preparation of
It is the professional responsibility of hygienists and the emergency drugs. This extends from turning on the
therapists to ensure that: oxygen supply and attaching the different types of face
masks, to the opening of drug ampoules, and the draw-
■ They know the location of, and have easy and prompt ing up and mixing of medications presented as powders
access to, all emergency equipment and drugs with solvents (e.g. glucagon and hydrocortisone hemi-
(Table 16.1). succinate). Adrenaline is available in glass ampoules and
CTOC16 6/29/06 18:01 Page 382
382 Clinical Textbook of Dental Hygiene and Therapy
1
Table 16.1 Emergency equipment and drugs required in the dental surgery.
Equipment Drugs
Pocket mask with one-way valve and oxygen inlet Oxygen
Self-inflating bag , valve and mask with reservoir (e.g. Ambu bag) in various sizes Adrenaline (epinephrine)
2
Oropharyngeal airways (various sizes) Glyceryl trinitrate (GTN)
Oxygen therapy masks with tubing and appropriate connectors for oxygen cylinder Aspirin
Syringes and needles to deliver emergency drugs by appropriate routes Glucose
Intravenous cannulae and adhesive tape Glucagon
Independently powered portable suction apparatus with wide-bore aspiration tips Salbutamol inhaler
3 5
Blood pressure monitor Chlorphenamine
Pulse oximeter3 Hydrocortisone sodium succinate5
4
Automated external defibrillator Midazolam
Automated blood glucose measuring device4 Flumazenil (if sedation with benzodiazepines
is undertaken)
1 Equipment should be free from natural rubber latex and resuscitation equipment must be available in suitable sizes for children.
Drugs must be available in preparations free from natural rubber latex, whenever possible
2 These are also referred to as Guedel’s airway
3 Essential in a practice that carries out intravenous sedation
4
This is not currently considered to be an essential item of equipment but clinical opinion may change
5
These drugs are not considered to be first-line drugs
in preloaded syringes (with or without needles), and ■ Have knowledge of how to identify medical emer-
staff should be confident in preparing the drugs held in gencies and provide immediate management of
the practice. Preloaded syringes are more user-friendly, anaphylactic reaction, hypoglycaemia, upper respira-
although there are still training issues to be addressed in tory tract obstruction, cardiac arrest, fits, vasovagal
assembling Minijet syringes. attack, inhalation or ingestion of foreign bodies and
It is imperative that training exercises are aimed at haemorrhage (The Development of the Dental Team:
team building and therefore should be non-threatening. General Dental Council, 2005).
Consideration should be given to the management of Hygienists and therapists are capable of independent
patients who have collapsed in areas other than the practice and may work when a dentist is away from the
dental chair or surgery. Toilets, with their confined space, dental practice. When the dentist is present it is probable
can be particularly awkward and problematic. Locked that he or she will assume the role of team leader in a
toilet doors should be able to be opened from the outside medical emergency, although another, more experienced
so that emergency access can be obtained. Formal courses clinical member of the team may assume this role. In the
using scenario training for medical emergencies are pro- event of an emergency it is hoped that those present
vided by some postgraduate deaneries. Immediate life would work as a team, with many of the staff making
support(ILS) courses are organised by the Resuscitation valuable contributions to the management of the patient.
Council (UK). The authors consider it best practice for all However, a dentist may not be on the premises and a
clinical members of the dental team to receive annual therapist/hygienist may be the most senior person and
training to ILS standards. lead the team; in fact, he or she may be the only staff mem-
When first commencing work in a new practice it ber present. It is therefore important that the hygienist/
should be standard practice to identify where the emer- therapist understands their role fully in a medical crisis
gency drugs and equipment are kept. You should be and has a clear idea of what actions they would be pre-
satisfied that these are adequate and comply with current pared to carry out.
guidance. Participation in team training for emergencies The guidance given by the GDC clearly indicates that
should ideally be part of the induction process when the hygienist/therapist would be expected to perform
starting in a new place of work. CPR; it would be unacceptable for any clinical member
of the dental team not to attempt CPR on a patient in
The role of the hygienist/therapist cardiorespiratory arrest. There remains some uncertainty
from the guidance given by the GDC as to what would
The General Dental Council (GDC) states that dental be expected from a therapist/hygienist with regard to
hygienists and therapists should: the administration of drugs. It can be assumed from the
guidance given by the GDC that hygienists/therapists
■ Be competent at carrying out resuscitation techniques. should administer oxygen. The GDC state that the
CTOC16 6/29/06 18:01 Page 383
Medical emergencies and their management 383
hygienist/therapist should have knowledge of how to ment. When this occurs the therapist/hygienist should
identify medical emergencies and provide immediate seek advice from the dentist to see if it is safe to proceed
management of anaphylactic reaction, hypoglycaemia, with operative treatment. In the absence of any dentists,
upper respiratory tract obstruction, cardiac arrest, fits, a member of The Medicines Information Service, who
vasovagal attack, inhalation or ingestion of foreign bodies, advise on drug therapy relating to dentistry, can be
and haemorrhage. Does how to providemean that you should contacted by telephoning 0151 794 8206 (in the UK).
provide? It is the authors’ opinion that hygienists and Patients (and sometimes guardians or carers) do not
therapists should be able to administer first-line drugs always disclose an accurate medical and drug history.
for the patient. Therefore in the medical emergency sec- When important questions remain unanswered or there
tion, which describes the comprehensive management appear to be inconsistencies or conflicting information
required for each emergency, the hygienist or therapist then clarification should be sought from the patient’s
would be expected to carry out essential primary treat- medical practitioner. Operative treatment should not be
ment. This includes the use of the following drugs: oxygen, undertaken in the absence of a reliable medical history.
adrenaline, glucose, glucagon, midazolam, glyceryl trinitr- When a patient declares a significant medical condition
ate, aspirin and salbutamol. Further post-qualification it is often necessary to ask further in-depth questions in
training may result in new drugs being added to this list. order to assess potential risks. An example of this is in
It must be appreciated that the overwhelming majority patients who have epilepsy; it is essential to know how
of clinical dental personnel are uncomfortable in manag- well their epilepsy is controlled and when they had their
ing a medical emergency and are unlikely to feel last seizure. The type of epilepsy should be documented
confident in administering emergency drugs, other than and the patient asked for a description of their seizures.
oxygen. This is because their experience is likely to be It is also helpful to know if they have warnings about
based solely upon their academic knowledge and clinical their attacks. It is important to identify if they have ever
skills acquired during simulation training (hence its gone into status epilepticus, and if so, how often. Any trig-
importance). Other than the management of faints, most gers that have been identified as precipitating a seizure
dental staff will have little (if any) experience of manag- should be documented in the records. Whilst all types of
ing medical emergencies for real. epilepsy should be recorded, the most dangerous seizure
in the dental surgery is a generalised seizure, due to the
Avoidance of a medical emergency greater possibility of injury and post-seizure complica-
tions. Patients who have frequent seizures should be
asked for details about their recovery; for example, some
Whilst it is accepted that all members of the dental team patients sleep after a seizure. Ask this group of patients
should be prepared to manage a medical crisis, steps how they would like to be managed post seizure.
should always be taken to try and prevent an acute con- Treatment planning should be sensible and realistic
dition from arising. In essence this involves: and the medical and social needs of each patient should be
■ Having an accurate contemporaneous record of the taken into account. The timing and duration of appoint-
patient’s medical and drug history. ments are important when treating patients with chronic
■ Having a realistic and appropriate treatment plan. disease. Table 16.2 highlights some factors that will
■ Identifying potential medical problems. influence treatment planning. Patients with diabetes
■ Observing the patient. should not be kept waiting and ideally treatment should
not interfere with the timing of the patient’s carbohydrate
Prior to treating any patient a detailed medical and intake or administration of their medication. Patients
drug history is essential, and this should be updated at who have debilitating illnessesand who get tired easily
each treatment session. Knowledge of a patient’s medical should have their dental appointments at a time that
status is part of risk assessment. Details of any medical is most suited to their lifestyle. Sometimes carers and
history previously recorded in the clinical records should patients who have severe disabilities are unable to attend
be read thoroughly and evaluated before the patient for early morning appointments. Patients who receive
enters the surgery. When treating a patient with a kidney dialysisshould usually be treated on a day when
significant medical and drug history, all staff involved in they are not dialysed. A patient who has had a myocardial
the care of the patient should know of, and understand, infarctionwithin the last 6 months should only undergo
the relevance (if any) of the patient’s current and past simple emergency dental treatment due to an increased
medical conditions. It is always prudent to ask patients if risk of dysrhythmias; routine, elective treatment should
they have taken their medication as usual. Occasionally a be deferred.
patient will have the misconception that they should It is important that therapists and hygienists recognise
stop their regular medication on the day of dental treat- dental anxiety in their patients. This is of paramount
CTOC16 6/29/06 18:01 Page 384
384 Clinical Textbook of Dental Hygiene and Therapy
Table 16.2 Considerations when treating patients with Table 16.3 Clinical monitoring.
a medical history.
Level of consciousness
When assessing a patient’s health record it is helpful to consider Assess the patient’s response to questions and commands and
the following possibilities: also their level of cooperation
■ Are there any medical conditions that can affect any aspect of Respiration
treatment? For example, in patients with cardiorespiratory At rest, respiration should be regular, effortless and quiet; breath
problems, is their breathing adversely affected by chair sounds should not be obvious. When there is obstruction on
position? In the patient with diabetes the timing and duration inspiration, increased respiratory signs are seen such as excessive
of the appointment need to take into consideration the timing abdominal movement. The number of breaths can be counted
of their anti-diabetic drug medication, meals and snacks. over a 30-second period and the rate calculated for 1 minute. The
Does the patient have an illness that affects blood clotting? respiration rate should be around 14–20 breaths per minute for
■ Is the medication taken by the patient likely to influence/modify an adult, but may be as high as 30 in a child
the proposed dental treatment? Is the patient on warfarin? Are
there any orofacial side effects associated with their medication? Pulse
■ Does the patient self-medicate with a preparation that may be Assess the rate, regularity and quality
useful in the prevention or management of a medical emergency?
Glyceryl trinitrate or bronchodilators such as a salbutamol inhaler Colour of the patient
should be easily accessible if needed urgently. Assess the pallor of the face, the colour of the fingers. Visual signs
■ Are there any known allergies? In particular are there any severe of central cyanosis will only be detected by a skilled operator when
allergies to substances (allergens) that the patient may be the arterial oxygen saturation falls to below 85%. Hypoxia is
exposed to in the dental surgery? Does the patient carry therefore not clinically noticeable in the early stages and if hypoxia
epinephrine (adrenaline) for self-administration? is a concern then the use of a pulse oximeter may be advisable.
Patients will normally have oxygen saturation levels of 95–100%
General mood, demeanour, composure and body language
Ascertain if the patient is relaxed or agitated. When a patient is
importance in those who have serious medical condi- receiving dental treatment the operator and nurse should be aware
tions that are exacerbated by stress (for example angina, of how comfortable or restless the patient is. A restless patient
hypertension or epilepsy). This group of patients should may fidget and appear tense; an anxious patient may have their
be asked if they are made anxious by any aspect of dental shoulders hunched and their hands may become clenched or
treatment, because pain control and effective anxiety tighten around the armrests
control are essential to avoid a crisis. It may be safer to
treat this cohort of anxious patients under sedation. Not
all patients are suitable for dental treatment in primary sometimes prevent an acute incident or prepare the
care. It is often necessary to refer patients who have dental team for prompt action in the early stages of a
severe unstable medical conditions to a specialist unit crisis. Knowing when to summon expert assistance is also
when operative dental treatment is required. If there is important. Always talk to the patient, ask them questions,
uncertainty about the safety of managing a patient in as this will allow you to assess their level of consciousness.
primary care, advice should be sought. Any deterioration in consciousness is to be taken seri-
It is always necessary to observe a patient clinically ously and treatment should be stopped immediately.
during dental treatment; careful observation will allow
early recognition and prompt management of the unwell Taking a pulse
or deteriorating patient (Table 16.3).
It is rare for a medical emergency to occur without A pulse results from the intraarterial pressure trans-
warning. When treating a patient there will usually be mitted to arteries by the contraction of the left ventricle.
signs and/or symptoms which indicate a deteriorating A pulse represents the heart rate. Pulse points can be
condition. When a patient looks unduly pale, flushed or found in many peripheralor majorarteries; often a pulse
ill, ask them if they are feeling unwell. It may just be that can be palpated (felt) when the artery crosses a bony
they had a disturbed sleep, have missed a meal or are prominence or it can be compressed against firm tissue.
recovering from an illness. Such information is helpful in The radial and brachial are the commonly used
evaluating the patient. Patients who are clearly unwell superficial pulses. The carotid and femoral pulses are
should have their dental treatment deferred. When a pati- major pulses and are used in the assessment of an uncon-
ent has missed a meal and looks pale it may be prudent to scious patient. In a baby, however, the brachial pulse is
administer glucose prior to treatment. Efforts should be used because the neck is poorly developed, making the
made to relax or reassure a patient who arrives in a dis- carotid pulse difficult to feel. An average resting pulse
tressed state before any operative treatment is undertaken. rate for an adult is around 80 bpm (range 60–100).
Early recognition of a distressed or unwell patient can Children’s pulse rates are faster.
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