Medical Emergencies
-> Minimal equipment for emergency use in Dentistry :
-> Minimal Drugs to be kept or emergency use in Dentistry :
-> Diabetic patients should have their normal meals and medication, and treatment should be caried out early morning o immediately after lunch ti prevent hypoglycemic collapses.
-> Assessment in emergencies - ABCDE :
- Central Cyanosis & Use of accessory breathing muscles like neck, are late sign of airway obstruction.
- Partial airway obstruction, air entry is diminished & Usually noisy.
- Inspiratory ‘stridor’ is caused by obstruction at the laryngeal level or above.
- Expiratory ‘wheeze’ suggests obstruction of the lower airways, which tend to collapse and obstruct during expiration. This is most commonly seen in patients with asthma or chronic obstructive pulmonary disease.
- Gurgling suggests there is liquid or semi-solid foreign material in the upper airway.
- Snoring arises when the pharynx is partially occluded by the tongue or palate.
-> Solution : In most cases, only simple methods of airway clearance are needed:
- Airway opening manœuvres – head tilt/chin lift or jaw thrust.
- Remove visible foreign bodies, debris or blood from the airway (use suction or forceps as necessary).
- Use a mask with an oxygen reservoir. Ensure that the oxygen flow is sufficient (15 litres per minute) to prevent collapse of the reservoir during inspiration.
• Breathing (B) :
- The normal respiratory rate adult rate is 12 to 20 breaths per minute and a child’s rate is between 20 and 30 breaths per minute.
- Assess the depth of each breath, the pattern (rhythm) of respiration and whether chest expansion is equal and normal on both sides.
-> Solution : use bag and mask (if trained) or pocket mask ventilation with supplemental oxygen while calling urgently for an ambulance.
• Circulation (C) :
- Measure the capillary refill time. [Apply cutaneous pressure for five seconds on a fingertip held at heart level (or just above) with enough pressure to cause blanching. Time how long it takes for the skin to return to the colour of the surrounding skin after releasing the pressure. The normal refill time is less than two seconds. A prolonged time suggests poor peripheral perfusion. Other factors (e.g. cold surroundings, old age) can also prolong the capillary refill time.]
- Count the patient’s pulse rate. [It may be easier to feel a central pulse (i.e. carotid pulse) than the radial pulse.]
- [Weak pulses in a patient with a decreased conscious level and slow capillary refill time suggest a low blood pressure.]
- Cardiac chest pain typically presents as a heaviness, tightness or indigestion-like discomfort in the chest. The pain or discomfort often radiates into the neck or throat, into one or both arms (more commonly the left) and into the back or stomach area.
-> Solution : Laying the patient down and raising the legs may be helpful. [In patients who do not respond to simple measures urgent help is needed and an ambulance should be summoned.]
- If the patient has sustained chest pain, give GTN spray if the patient has not already taken some. The patient may feel better and should be encouraged to sit upright if possible. Give a single dose of aspirin and consider the use of oxygen.
• Disability (D) :
- Review and treat the ABCs: exclude hypoxia and low blood pressure.
- Check the patient’s drug record for reversible drug-induced causes of depressed consciousness.
- Examine the pupils (size, equality and reaction to light).
- Measure the blood glucose to exclude hypoglycaemia, using a glucose meter.
• Solution : If blood glucose below 3.0 mmol per litre give the patient a glu-cose containing drink to raise the blood sugar (e.g. Glucogel; Dextrogel)
- Nurse unconscious patients in the recovery position if their airway is not protected.
• Exposure (E) : To assess and treat the patient properly loosening or removal of some of the patient’s clothes may be necessary. Respect the patient’s dignity and minimize heat loss. This will allow you to see any rashes (e.g. anaphylaxis) or perform procedures (e.g. defibrillation).
-> For giving I.M. for emergency drugs through clothing :
The mid-point between the pelvis and the knee is the preferred site.
------- Common Emergencies -------
• Collapse :
-> The principles of the chain of survival, which applies to emergencies where the patient is not breathing and has no pulse, involve four stages:
- Early recognition and call for help
- Early CPR
- Early defibrillation
- Early ALS.
•Simple Faint (Syncope) : It is associated with a loss of postural tone, and there is spontaneous recovery.
-> Predisposing factors for vasovagal attack include:
- Anxiety
- pain
- fatigue
- fasting (rarely)
- high temperature and relative humidity.
-> Other causes of sudden loss of consciousness include:
- situational syncope provoked by coughing, micturition (urination) or postural change
- sudden cardiac syncope due to arrhythmia or circulatory obstruction – typically in older people
- orthostatic hypotension(A form of low blood pressure that happens when standing up from sitting or lying down.)
- neurological disorders.
-> Signs and symptoms of a simple faint include:
- premonitory dizziness, weakness or nausea
- pallor
- cold, clammy skin
- dilated pupils
- pulse that is initially slow and weak, then rapid and full
- loss of consciousness.
-> Very rarely, patients can suffer malignant vasova-gal syncope with recurrent, severe and otherwise unexplained syncope; their clinical history is intermediate between that of vasovagal and cardiac syncope, and diagnosis is confirmed by a tilt test.
• Anaphylaxis : Anaphylaxis is the most severe allergic response and manifests with acute hypotension, bronchospasm, urticaria rash and angioedema.
-> The causal agents include:
- penicillins – the most common cause, but also other antimicrobials (cephalosporins, sulphonamides, tetracyclines, vancomycin)
- latex
- muscle relaxants
- non-steroidal anti-inflammatory drugs (NSAIDs)
- opiates
- radiographic contrast media
- others – vaccines, immunoglobulins, various foods and insect bites.
-> Diagnosis :
- facial flushing, itching, paraesthesiae, oedema[fluid retention in the body] or sometimes urticaria[skin rash], or peripheral cold clammy skin
- stridor or wheeze[high-pitched whistling sound made while breathing]
- abdominal pain, nausea[urge to vomit.]
- loss of consciousness
- pallor progressing to cyanosis
- rapid, weak or impalpable pulse.
-> Managment :
- Recognition that they are seriously unwell
- An early call for help
- Initial assessment and treatments based on an ABCDE approach
- Treat the greatest threat to life first.
- Adrenaline (epinephrine) therapy if indicated[Patients should carry 2 EpiPens® with them because >35% of patients may require more than one adrenaline dose and up to 20% of patients will go on to develop a biphasic anaphylactic response sometimes hours later. The standard dosage of adrenaline supplied by an EpiPen for adults is 0.3 mL of 1 in 1000 (0.3 mg). Child-sized dosages (0.15 mg) are available as the EpiPen JR.]
- Investigation and follow-up by an allergy specialist.
• Cardiac Arrest : Ventricular fibrillation accounts for most sudden cardiac arrests. Causes include myocardial infarction, hypoxia, drug overdose, anaphylaxis, severe infection or severe hypotension.
- Maintain BLS.
• DIABETIC COLLAPSE: HYPOGLYCAEMIA -
- Remember that a collapse in a diabetic may be caused by other emergencies, e.g. a faint or myocardial infarction. Ischaemic heart disease is common in long-standing diabetes.
- Hypoglycaemia may present as a deepening drowsiness, disorientation, excitability or aggressiveness, especially if it is known that a meal has been missed.
• Fitting (Suffering a sudden attack or convulsion, like Epileptic seizure) : Various factors may precipitate a fit, including not eating, cessation of anticonvulsant therapy, menstruation and some drugs, such as alcohol, flumazenil or tricyclic antidepressants, following hypoxia from loss of consciousness for other reasons or in hypoglycaemia.
-> Diagnosis of a tonic–clonic (grand mal) seizure is as follows:
- loss of consciousness with rigid, extended body, which is sometimes preceded by a brief cry
- widespread jerking movements
- possible incontinence of urine and/or faeces
- slow recovery with the patient sometimes remaining dazed (post-ictal).
• Chest Pain : Patients with ‘unstable’ angina and those with a recent history of hospital admission for ischaemic chest pain have the highest risk, and should not be considered for routine dental treatment in primary care.
-> Diagnosis:
- severe crushing
- retrosternal pain radiating down the left arm
- breathlessness that may be described as ‘heartburn’
- vomiting and loss of consciousness if there is an infarct[Necrosis]
- weak or irregular pulse if there is an infarct.
• Shortness of breadth :
• Acute severe asthma :
-> Risk Factors :
- Anxiety
- Infection
- Exposure to allergens or drugs
- take oral medication in addition to inhaled β2 agonists and corticosteroids
- use a nebulizer regularly at home
- have required oral steroids for their asthma within the last year
- have been admitted to hospital with asthma within the last year.
-> Diagnosis:
- breathlessness
- expiratory wheeze
- use of accessory muscles – shrugging the shoulders with each respiratory cycle with increased severity
- rapid pulse (usually over 110 beats/min) with increasing severity but this may slow in life-threatening exacerbation.
• FOREIGN BODY RESPIRATORY OBSTRUCTION :Prevention of inhalation of foreign bodies, is far better than the event occurring.
-> Diagnosis :
- irregular breathing with crowing or croaking on inspiration
- violent respiratory efforts using accessory muscles
- deepening cyanosis.
• STROKE :
-> Diagnosis :
- loss of consciousness
- unilateral weakness of the arm and leg
- facial palsy.
• ADRENAL CRISIS: COLLAPSE OF A PATIENT WITH A HISTORY OF CORTICOSTEROID THERAPY :
Addison's Disease : A disorder in which the adrenal glands don't produce enough hormones.
• Reactions to Intravascular injection of local anaesthetic agent :
-> Diagnosis :
- agitation [a state of anxiety or nervous excitement.]
- confusion
- drowsiness
- fitting
- eventually, loss of consciousness.
