CLINICAL PROTOCOL FOR THE MEDICAL EMERGENCY TREATMENT OF DENTAL PATIENTS

Transcription

1 CLINICAL PROTOCOL FOR THE MEDICAL EMERGENCY TREATMENT OF DENTAL PATIENTS INTRODUCTION Medical emergency treatments are based on current best practice. (See references) This protocol should be kept in a clear designated/ dedicated place within each surgery. For domiciliary visits it should be kept inside the box used to store the community dental medical emergency medicines. All members of staff should familiarise themselves with: the contents of this protocol where this protocol can be found within the surgery A systematic approach to recognising the acutely ill patient based on the Airway, Breathing, Circulation, Disability, and Exposure ABCDE principles is recommended. However: For patients who are unresponsive, follow the Trust Procedure for: Basic Life Support (BLS). See appendix two for algorithm BLS SCOPE To give guidance on the recommended treatment of common medical emergencies. To direct staff to transfer patients urgently to secondary care when appropriate. This document is not a patient group direction and therefore all emergency treatment should be under the direction of dentist; however provision under the Medicines Act allows suitably trained members of staff to administer the medication included in this protocol for the purpose of saving life. The exception to this is buccal midazolam which must be administered under the direction of a dentist. The prescriber should consider the allergy status of the patient and any potential contraindications, but this should not be at the cost of delaying urgent care. All treatments administered to patients must be recorded fully in the patient s record, including batch numbers and expiry dates. All treatments such as glyceryl trinitrate spray, salbutamol inhaler, the Volumatic spacer device and oxygen mask and tubing are for single patient use only and if used a replacement stock must be obtained. All treatments should be retained in the original manufacturer s container. A delegated staff member must be responsible for checking the contents of the emergency box, ensuring no medication is expired and the contents are fit for use. These guidelines do not cover standard resuscitation measures. Dental Service 1/15

2 TRAINING All staff in the Trust are required to comply with mandatory training, as specified in the Trust s Mandatory Training Matrix. Clinical Staff are also required to comply with service specific mandatory training as specified within their service training matrix. RELATED POLICIES Please refer to relevant Trust policies and procedures CONTENTS OF COMMUNITY DENTAL MEDICAL EMERGENCY BOX Adrenaline 1mg in 1ml ampoules (1 box) plus syringes and needles Aspirin 75mg dispersible tablets (1 box) Glucagon Injection, 1mg in 1ml vial with syringe pack (1) Glucose 40% oral gel 25g (3x 25g pack) Glyceryl trinitrate 400 micrograms per oral spray (over labelled pack) (1) Midazolam buccal liquid/gel 10mg in 1ml (1x 5ml pack) Salbutamol inhaler 100 micrograms per metered dose (over labelled pack) (1) Volumatic spacer device (1) The following equipment must also be available: Oxygen cylinders (size D) with pressure reduction valve and flow meter Bag valve, mask and tubing. Pocket mask Nasal cannula Non rebreathing mask Orophangeal airways Syringes Drawing-up needles Drug delivery needles Blood glucose monitoring machine. Blood glucose testing strips (check expiry dates once opened the shelf life is shortened) Automated external defibrillator (AED) Pulse oximeter Monitoring Resuscitation Equipment The service will have a system in place for recording daily checks of resuscitation equipment to include:- Date Time Signature and full name Designation CONTENTS: FOR MEDICAL EMERGENCIES Dental Service 2/15

3 Page No. Page No Anaphylaxis 3. Hypoglycaemia 9. Asthma 4. Panic Attacks/ 11. Hyperventilation Cardiac Emergencies 6. Stroke 11. Unconscious patient not breathing normally 7. Syncope or fainting 12. Choking and aspiration 7. Adrenal Insufficiency 12. Epileptic Seizures 8. Anaphylaxis See also the Trust Procedure for Managing an Anaphylactic Emergency. Anaphylaxis in dentistry may follow the administration of a drug or contact with substances such as latex. In general, the more rapid the onset of reaction the more profound it tends to be. Symptoms may develop within minutes and rapid treatment is essential. Symptoms and Signs of Anaphylaxis The wide range of possible presentations can cause diagnostic difficulty, signs and symptoms may include: Paraesthesia, flushing and swelling of the face Generalised itching, especially of the hands and feet Bronchospasm and larynogospasm (with wheezing and difficulty in breathing) Rapid weak pulse with fall in blood pressure and pallor, finally cardiac arrest Management of Anaphylaxis a. Telephone for an ambulance immediately and state that there is a case of suspected anaphylaxis b. Call for help from other Trust employed staff, if available. c. Assess the patient; check central pulses and respiration. d. Maintain a clear airway e. Lie the patient down, ideally with the legs raised (unless the patient has breathing difficulties). f. Give high flow oxygen (see also the SOP for: Handling, Use and Storage of Emergency Oxygen within Community Trust Services) g. If breathing stops, BLS should be performed h. Stay with the patient at all times i. All patients with clinical signs of shock, airway swelling or definite breathing difficulties, should be given adrenaline (epinephrine) 1:1000 (1mg in 1ml) administered by intramuscular (IM) injection (never subcutaneously). For Dental Service 3/15

4 information on dosing see below. The preferred site is the mid-point of the anterolateral aspect of the thigh. Dosages of adrenaline (epinephrine)1:1000 (1mg in 1ml) to be administered by intramuscular injection (IM) Age Dose of adrenaline (epinephrine) Volume of 1:1000 (1mg in 1ml) Under 6 months 150 micrograms IM 0.15ml 6 months to under 150 micrograms IM 0.15ml 6 years 6 12 years 300 micrograms IM 0.3ml Adults and children over 12 years 500 micrograms IM 0.5ml j. If there is no improvement in the patient s condition repeat the same dose at 5 minute intervals until the patient recovers or the ambulance arrives, monitor pulse and respirations and blood pressure, if machine available. k. Because of the possibility of delayed reactions, all individuals who have had an anaphylactic reaction should be sent to hospital, even if they may appear to have made a full recovery. l. Record all care in the patient s records including if known, the time of onset of the reaction and the circumstances immediately before the onset of symptoms. This information must be transferred with the patient to secondary care to help identify the possible trigger. m. The incident must be reported using the Trust Incident Reporting System, detailing all treatment administered within at least an hour of the incident or earlier if practicable. Asthma Patients with asthma may have an attack while in the dental clinic. The treatment will depend on the severity of the attack, however in all cases advise the patient or carer to make an appointment with their medical practitioner. This is because the patient may require a review of their prophylactic medication and the patient may require a course of oral steroids. Symptoms and Signs Breathlessness, wheezing on expiration Clinical features of life threatening asthma include Cyanosis or respiratory rate < 8 per minute Bradycardia (heart rate < 50 per minute) Exhaustion, confusion, decreased conscious level Clinical features of acute severe asthma include Inability to complete sentences in one breath Respiratory rate > 25 per minute Tachycardia (heart rate > 110 per minute) Management of life threatening asthma a. Assess the patient. Dental Service 4/15

5 b. Sit the patient upright. c. Transfer the patient to hospital immediately as an emergency. d. Whilst awaiting transfer give high flow rate oxygen (see also the SOP for: Handling, Use and Storage of Emergency Oxygen within Community Trust Services) e. Up to 10 puffs of salbutamol inhaler should be given through the Volumatic spacer device, repeating every 10 minutes if necessary until an ambulance arrives. f. If bronchospasm is part of a more generalised anaphylactic reaction and there are 'life-threatening' signs, an intramuscular injection of adrenaline should be given (see Anaphylaxis). g. A record of any treatment given should be recorded and sent with the patient to hospital, as long as this does not delay the transfer. Management of Acute Asthma a. Assess the patient. b. Sit the patient upright. c. Administer the patient s own short-acting beta2-adrenoceptor stimulant (2 puffs) or 2 puffs from a salbutamol inhaler 100 micrograms per metered dose. Administer further puffs if the patient does not respond rapidly. d. If the patient is unable to use the inhaler effectively, further doses to be given through the Volumatic spacer device. (Shake the salbutamol inhaler between administering each puff into the Volumatic). e. Continue to treat with 4 to 10 puffs of salbutamol inhaler through the Volumatic spacer device, repeating every 10 to 20 minutes if necessary. For children 2-18 years 1 puff of salbutamol inhaler via the Volumatic device every 15 seconds (max. 10 puffs) repeat at minute intervals as needed. f. If the response remains unsatisfactory, or further deterioration occurs, then the patient should be transferred urgently to hospital. A record of any treatment given should be recorded and sent with the patient to hospital. g. Whilst awaiting transfer give high flow rate oxygen (see also the SOP for Handling, Use and Storage of emergency oxygen within Community Trust Services) h. If asthma is part of a more generalised anaphylactic reaction follow the guidelines for anaphylaxis. If a patient, suffering from a severe episode of asthma, is deteriorating and does not respond to treatment with bronchodilators within 5 minutes of administration, then phone for an ambulance. Cardiac Emergencies Arrhythmias Dental Service 5/15

6 Sudden alterations in the patient s heart rate (very fast, very slow or irregular) may lead to a sudden reduction in cardiac output with loss of consciousness. The patient must be transferred immediately to hospital. Acute Coronary Syndromes (Angina and Myocardial Infarction) Key Signs: Progressive onset of severe, crushing pain in the centre and across the front of the chest; The pain may radiate towards the shoulders and down the arms or into the neck and jaw Symptoms include: Shortness of breath Increased respiratory rate Skin becomes pale and clammy Nausea and vomiting are common Pulse might be weak and blood pressure might fall Management of Angina If the patient has a history of angina the patient will probably carry glyceryl trinitrate spray or tablets and should be allowed to use them. Alternatively administer 1 to 2 sprays of glyceryl trinitrate 400 micrograms per oral spray. Hospital admission is not necessary if the symptoms are mild and resolve rapidly after treatment with glyceryl trinitrate Management of Myocardial Infarction The pain of myocardial infarction is similar to that of angina but generally more severe and more prolonged. a. Call for help from other Trust employed staff b. Telephone for an ambulance immediately and state that there is a case of suspected myocardial infarction c. Allow the patient to rest in the position that feels the most comfortable d. Give high flow oxygen (see also the SOP for: Handling, Use and Storage of Emergency Oxygen within Community Trust Services) e. Administer 1 to 2 sprays of sublingual glyceryl trinitrate spray to relieve pain f. Administer aspirin orally 300mg as a single dose (4x 75mg soluble tablets) g. Reassure the patient as much as possible to reduce further anxiety h. A note to say that aspirin has been administered must be sent with the patient to the hospital, together with details of any dental treatment given that might contraindicate thrombolytic therapy i. If the patient collapses and loses consciousness attempt standard resuscitation measures. Management of the unconscious patient who is not breathing normally Dental Service 6/15

7 In the first few minutes after cardiac arrest, the patient may barely be breathing, or taking infrequent, noisy, gasps. This is often termed agonal breathing and must NOT be confused with normal breathing. Normal respiratory rate is between breaths per minute. If there is any doubt as to whether breathing is normal, act as if it is NOT normal. If a patient is unconscious and not breathing normally, follow the Trust Procedure for Basic Life Support (BLS) Look, listen and feel for NO MORE than 10 seconds to determine if the patient is breathing normally. Open the patient s airway and ensure it is clear. Look for chest movement Listen at the patient s mouth for breath sounds Feel for air on your cheek. Telephone for an ambulance and transfer the patient to hospital as an emergency. Commence BLS Attach the patient to an AED and follow the instructions, including delivering shocks if advised. Choking and aspiration Dental patients are susceptible to choking and aspiration due to the presence of blood and secretions in their mouths for prolonged periods, suppressed pharyngeal reflexes due to local anaesthesia or the presence of impression material or dental equipment in their mouths. Signs and symptoms include: Patient may cough and splutter Patient may complain of breathing difficulty Breathing may become noisy on inspiration (stridor) Patient may develop paradoxical chest or abdominal movements Patient may become cyanosed and lose consciousness Choking a. Remove any visible foreign bodies in the mouth and pharynx. b. Encourage the patient to cough. c. If the patient is unable to cough but remains conscious, commence back blows followed by abdominal thrusts. d. If the patient becomes unconscious, BLS should be started immediately; this may also help to dislodge the foreign body. e. Call an ambulance and transfer patient to hospital as an emergency. f. The incident must be reported using the Trust Incident Reporting System, detailing all treatment administered within at least an hour of the incident or earlier if practicable. Dental Service 7/15

8 Aspiration a. Encourage the patient to cough vigorously b. Give high flow rate oxygen (see also the SOP for: Handling, Use and Storage of Emergency Oxygen within Community Trust Services) c. Up to 4 puffs of salbutamol inhaler should be given through the Volumatic spacer device, repeating every 10 to 20 minutes if necessary. For children 2-18 years 1 puff of salbutamol inhaler via the Volumatic device every 15 seconds (max. 10 puffs) repeat at minute intervals as needed d. If you suspect that a large fragment has been inhaled or swallowed but there are no signs or symptoms, refer the patient to hospital for x-ray and removal of the fragment if necessary. e. If the patient is symptomatic following aspiration, refer them to hospital as an emergency. Epileptic Seizures Patients with epilepsy must continue with their normal dosage of anticonvulsant medicines when attending for dental treatment. Symptoms and Signs of Epileptic Seizures Key Signs: Sudden loss of consciousness, patient may become rigid, fall, might give a cry and becomes cyanosed (tonic phase) After 30 seconds, there are jerking movements of the limbs; the tongue may be bitten (clonic phase) Symptoms include: Brief warning or aura (This is variable) Frothing from the mouth Urinary incontinence Fitting may be a presenting sign of hypoglycaemia and should be considered in all patients, especially known diabetics and children The seizure typically lasts a few minutes; the patient may then become flaccid but remain unconscious. After a variable time the patient regains consciousness, but may remain confused for a while Management of Epileptic Seizures a. During a convulsion try to ensure the patient is not at risk from injury, but make no attempt to put anything in the mouth or between the teeth Dental Service 8/15

9 b. Give high flow oxygen (see also the SOP for: Handling, Use and Storage of Emergency Oxygen within Community Trust Services). c. Do not attempt to restrain convulsive movements. d. After convulsive movements have subsided place the patient in the recovery position and check the airway. e. After the convulsion the patient may be confused and may need reassurance and sympathy. The patient should not be sent home until they are fully recovered. Transfer the patient to hospital if it was the first episode of epilepsy or if the convulsion was atypical, prolonged or repeated or if injury occurred. f. If a seizure lasts longer than 5 minutes or there are multiple seizures, without full recovery (status epilepticus) give buccal midazolam and telephone for an ambulance. A record of any treatment given should be sent with the patient if they are transferred to hospital. Dosages of midazolam buccal liquid/gel (10mg / 1ml) Age Dose Volume Adult and child over 10 years 10mg 1ml 5 to 10 years 7.5mg 0.75ml 1 to 5 years 5mg 0.5ml 6 months to 1 year 2.5mg 0.25ml It should be noted that midazolam buccal liquid/gel is not licensed for use in status epilepticus; however its use for this indication is supported by The Resuscitation Council (UK). g. If the patient remains unresponsive check blood glucose, to eliminate hypoglycaemia Hypoglycaemia Insulin-treated diabetic patients attending for dental treatment under local anaesthesia should inject insulin and eat meals as normal. Patients can often recognise the symptoms themselves and this state should respond to oral glucose (e.g. sugar in water, glucose gels or glucose tablets). Symptoms and Signs of Hypoglycaemia Dental Service 9/15

10 Key Signs: Aggression and confusion Sweating Tachycardia (heart rate >110 min) Change of behaviour, truculence Pins and needles in lips and tongue Hunger Headache (occasionally) Double vision Symptoms include: Shaking and trembling Difficulty in concentration/vagueness Slurring of speech Headache Fitting/ seizures Unconsciousness Palpitations Children may not have such prominent changes but may appear unduly lethargic Confirm the diagnosis by measuring blood glucose Management of Hypoglycaemia a. Early stages: when the patient is co-operative and conscious, give oral glucose (glucose 40% oral gel 25g) by mouth. b. In more severe cases, if glucose cannot be given by mouth, if it is ineffective or if the hypoglycaemia causes unconsciousness, administer glucagon via the IM route: for dosage information see below: Dosages of glucagon 1mg in 1ml to be administered via the intramuscular route Age Dose Volume Child under 8 years or 500 micrograms 0.5ml of body-weight under 25Kg Adult or child over 8 years or body-weight over 25Kg 1 mg 1 ml c. Once the patient regains consciousness oral glucose must be administered as above. Re-check blood glucose after 10 minutes. d. After initial treatment, a snack providing sustained availability of carbohydrate (e.g. a sandwich, fruit, milk and biscuits) can prevent blood- glucose concentration falling again e. The patient may go home if they are fully recovered and they are accompanied. Their General Practitioner should be informed and they should not drive. If glucagon is ineffective and the patient remains unresponsive telephone for an ambulance and give high flow rate oxygen (follow the Trust SOP for Handling, Use and Storage of Emergency Oxygen within Community Trust Services) The patient must also be admitted to hospital if hypoglycaemia is caused by an oral antidiabetic drug. Panic Attacks/ Hyperventilation Dental Service 10/15

11 Signs and symptoms Key signs Muscle tension Sweating Key symptoms Increased breathing Rapid heart rate In most patients these will resolve with simple reassurance. Behavioural Management Display calm reassurance Establish effective communication with the patient Be open and honest; let the patient see who you are Use consistent verbal and nonverbal communication Explain procedures and answer any questions (explain when there may be discomfort with a procedure and what you will do to make procedures pain-free ) Talk to the patient if he or she displays signs of anxiety (for example, You seem tense today would you like to talk about it?) Physical management Encourage the patient to use rebreathing techniques. Stroke When stroke arrives act F.A.S.T. FACIAL weakness: Can the person smile? Has their mouth or eye drooped? ARM weakness: Can the person raise both arms? SPEECH problems: Can the person speak clearly and understand what you say? TIME to call for an ambulance A speedy response can help reduce the damage to a person s brain and improve their chances of a full recovery. A delay in getting help can result in death or long-term disabilities. Give high flow rate oxygen (see also the SOP for: Handling, Use and Storage of Emergency Oxygen within Community Trust Services) If the patient is unconscious, secure their airway and place in the recovery position. Syncope or fainting Dental Service 11/15

12 Insufficient blood supply to the brain results in the loss of consciousness. The commonest cause is a vasovagal attack or simple faint (syncope) due to emotional stress. Symptoms and Signs of Syncope Key Signs: Patient feels faint, dizzy, light headed Low blood pressure Yawning and slow pulse Dilated pupils Loss of consciousness Symptoms include: Pallor and sweating Nausea and vomiting Muscular twitching Management of Syncope a. Check the patients airway is clear and that the patient is breathing normally b. Lay the patient as flat as is reasonably comfortable and in the absence of associated breathlessness, raise the legs to improve cerebral circulation. c. Loosen any tight clothing around the neck d. Once consciousness is regained, give oral glucose e. If the patient remains unconscious then telephone for an ambulance and continue to monitor the patient s breathing every minute. f. If the patient remains unresponsive check blood glucose, to eliminate hypoglycaemia. Other possible causes Postural hypotension can be a consequence of rising abruptly or of standing upright for too long; antihypertensive drugs predispose to this. When rising, susceptible patients should take their time. Management is as for vasovagal attack. Under stressful circumstances, some patients hyperventilate. This gives rise to feelings of faintness, but does not usually result in syncope. In most cases reassurance is all that is necessary; rebreathing from cupped hands or a bag may be helpful but calls for careful supervision. Adrenal Insufficiency Adrenal insufficiency may follow prolonged therapy with corticosteroids and can persist for years after stopping. A patient with adrenal insufficiency may become hypotensive under the stress of a dental visit 4.1 Management of Adrenal Insufficiency a. Lay the patient flat b. Give high flow oxygen (see also the SOP for: Handling, Use and Storage of Emergency Oxygen within Community Trust Services) c. Transfer patient urgently to hospital DETERIORATING PATIENTS Dental Service 12/15

13 Should a patient deteriorate the Trust Deteriorating Patient Policy must be followed and an SBAR (Situation, background, assessment and recommendations) completed when referring patient to emergency services and all treatment given recorded in the patient s health records. INCIDENT REPORTING Clinical incidents or near misses must be reported via the Trust s incident reporting system. SAFEGUARDING In any situation where staff may consider the patient to be a vulnerable adult, they need to follow the Trust Safeguarding Adult Policy and discuss with their line manager and document outcomes. EQUALITY ASSESSMENT During the development of this protocol the Trust has considered the clinical needs of each protected characteristic (age, disability, gender, gender reassignment, pregnancy and maternity, race, religion or belief, sexual orientation). There is no evidence of exclusion of these named groups. If staff become aware of any clinical exclusions that impact on the delivery of care a Trust Incident form would need to be completed and an appropriate action plan put in place. References British National Formulary 64 September 2012 Medicines, Ethics and Practice.The professional guide for pharmacists. Ed 36:July Resuscitation Council (UK) Standards for Clinical Practice and Training for Dental Practitioners and Dental Care Professionals in General Dental Practice July 2006 (revised December 2012). Scottish Dental CEP. Drug Prescribing for Dentistry: Dental Clinical Guidance Aug Trust policies: Trust Procedure for Basic Life Support (BLS) Adult. Trust Procedure for Managing an Anaphylactic Emergency SOP for Handling, Use and Storage of Emergency Oxygen within Community Trust Services APPENDIX ONE Dental Service 13/15

14 CONTROL RECORD Title Clinical Protocol for the Medical Emergency Treatment of Dental Patients Purpose To promote safe and effective medical emergency treatment for dental patients Author Quality and Governance Service (QGS) Equality Assessment Integrated into procedure Yes No Subject Experts Head of Dental Services Andrew Kwasnicki Dentist Jackie Edwards Trust Pharmacist Lisa Knight Governance Pharmacist Tom Meade Resuscitation Officer Wirral Heart Support Document Librarian QGS Groups consulted with :- Medicines Management Group and Resuscitation Group Infection Control Approved December 2012 Date formally approved by February 2013 the Quality, Patient Experience and Risk Group Method of distribution Intranet Archived Date Location:- S Drive QGS Access Via QGS VERSION CONTROL RECORD Version Number Author Status Changes / Comments Version 1 N To reflect current best practice and maintain patient safety Status New / Revised / Trust Change Dental Service 14/15

15 APPENDIX TWO Adult Basic Life Support UNRESPONSIVE? Shout for help Open airway NOT BREATHING NORMALLY? Call chest compressions 2 rescue breaths 30 chest compressions Dental Service 15/15