MEDICAL EMERGENCIES (PART 1) IDENTIFYING AT RISK PATIENTS AND IDENTIFYING THE CONTENTS OF THE EMERGENCY DRUG KIT

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1 MEDICAL EMERGENCIES (PART 1) IDENTIFYING AT RISK PATIENTS AND IDENTIFYING THE CONTENTS OF THE EMERGENCY DRUG KIT Aims To explain the categories of patients that may be considered as being at risk during dental procedures. To identify the drugs required for the emergency drug kit. To identify the use of each drug contained in the emergency drug kit. To understand the minimum emergency equipment that should be available during a medical emergency. Objectives You will be able to identify those patients who may be considered to be at risk of a potential medical emergency during dental treatment. You will understand the requirements for the emergency drug kit and emergency equipment that should be available in your dental practice. You will understand the use for each item in the drugs kit, which will enable you to assist the clinician should a medical emergency arise in your practice. Introduction If by the term emergency we mean a situation where a patient s life is in immediate danger, then we have to admit, thankfully, that there are very few true emergencies in the dental surgery. It is relatively easy to be skilful in techniques that are repeated frequently. Emergency care is performed only occasionally and in instances that involve life saving measures, may be performed once in many years. A survey of general dental practitioners conducted over a ten-year period reported a medical emergency occurring, on average, once in every 3-4 years in dental practice. 1 Although rare, real emergencies can arise, and it is extremely important that the dental nurse can recognise the emergence of such a situation and competently fulfil their role in assisting the dentist during an emergency situation. The General Dental Council stipulate that: There are at least two people available to deal with potential medical emergencies when treatment is planned to take place All members of staff, not just the registered team members, know their role if a patient collapses or if there is another kind of medical emergency

2 All members of staff who might be involved in dealing with a medical emergency are trained and prepared to deal with such an emergency at any time, and practise together regularly in a simulated emergency so they know exactly what to do. 2 As part of your continuing professional development (CPD) you must complete at least 10 hours of verifiable CPD on medical emergencies over a 5-year cycle. 3 We will provide you with two articles on Medical Emergencies each year but you will need to ensure that you also undertake practical training each year. This article will enable you to identify those patients that may considered to be at a higher risk of a medical emergency during treatment and the items contained within the emergency drug kit that may be required to treat them. The Emergency Drug Kit Each member of the dental team should know where the emergency drugs kit is kept and know their role should an emergency arise. The drugs should be stored in a sealed box, which is clearly labelled except for the items, which need refrigerating. These need to be stored in a separate fridge from that containing food. The box should be placed in a cupboard that is easily accessible to all members of the Dental Team. Certain drugs should be available in all dental surgeries and should be easily accessible should an emergency situation arise. These drugs should be standardised throughout the UK. 4 Table 1 contains the recommended drugs from the Resuscitation Council that should be available in general dental practice and their use. Whilst looking at this table, examine Page 2 of 8

3 your own drug kit to see that it contains these items and familiarise yourself with the indication for these drugs so that you are able to locate the correct drug for the dentist in a medical emergency. Drug Use Glyceryl Trinitrate (GTN) spray (400 micrograms/dose) Angina Salbutamol aerosol inhaler (100 micrograms/actuation) Asthma Adrenaline injection (1:1000, 1mg/ml) Anaphylaxis Acute angio-oedema Aspirin dispersible (300mg) Myocardial infarction Glucagon injection 1mg Diabetic Crisis Oral glucose solution/tablets/gel/powder Diabetic Crisisconscious patient Midazolam 5mg/ml or 10mg/ml (buccal or intranasal) Epilepsy Oxygen All medical emergencies except hypoventilation Table 1. Drugs list 5 Your drug kit may also contain Chlorpheniramine, which may be used for anaphylaxis, and hydrocortisone sodium succinate, which may be used for adrenal crisis or as a second line drug for asthma or anaphylaxis. Standardised equipment throughout the UK should also be available should a medical emergency arise. Table 2 lists the minimum recommended equipment that should be available. Whilst looking at this table familiarise yourself with these pieces of equipment and ensure that you will be able to locate the equipment quickly if necessary. Suggest to your dentist that you practice as a team to locate and assemble the equipment that may be required during a medical emergency. MINIMUM RECOMMENDED EQUIPMENT Portable oxygen cylinder (D size) with pressure reduction valve and flow meter Oxygen facemask with tubing. Basic set of Oropharyngeal airways (sizes 1,2,3 and 4). Pocket mask with oxygen port. Self-inflating bag and mask apparatus with oxygen reservoir and tubing (1 litre size bag) where staff have been appropriately trained. Variety of well fitting adult and child facemasks for attaching to self-inflating bag. Portable suction with appropriate suction catheters and tubing e.g. the Yankauer sucker. Single use sterile syringes and needles. Spacer device for inhaled bronchodilators. Automated blood glucose measurement device. Automated External Defibrillator. Page 3 of 8

4 Table 2. Minimum equipment that should be available within the dental practice for medical emergencies 6 It is important that a planned replacement programme should be in place so that drugs and equipment can be replaced before their expiry date is reached. 7 Figure 1 is an example of a possible re-order system. Figure 1. Example of Re-order List The Medical History Although any patient could potentially have a medical emergency during treatment, an upto-date medical and drug history, can enable the dental practitioner to identify those patients who may be at risk and take measures to reduce the likelihood of a medical emergency occurring. 8 The medical history should be checked at each appointment and changes noted. If a patient is identified as being at particular risk this should be highlighted clearly on the patient s notes or in the computer records. If written notes are used in your surgery ensure that the medical history is not visible on the front of the patient s notes as this may breach patient confidentiality. Identifying patients who may be at a higher risk of having a medical emergency during dental treatment Patients that, according to the Resuscitation Council (2008), may be defined as at risk are patient s that suffer from or are at risk of; Angina Asthma Diabetics Allergies Epilepsy 9 Page 4 of 8

5 Angina The Resuscitation Council Guidelines (2008) state Patients with unstable angina, nocturnal angina and those with a recent history of hospital admission for angina have the highest risk and may require some or all of their treatment in a more medically supported environment These patients are at risk because Angina can lead to a Myocardial Infarction. 10 Minimising the Risk Angina patients that can be treated in the surgery should carry their sublingual Nitroglycerine tablets or spray with them and this should be placed on the tray so that the patient can locate it quickly if it is required. Patients should be kept as calm as possible, waiting times kept to a minimum and appropriate anaesthetic administered to minimise stress. Asthma During an asthma attack the patient suffers from constriction of the bronchioles of the lungs. The attack can range from wheezing and shortness of breath to a life threatening condition. The Resuscitation Guidelines Council (2008) states Those at highest risk of having an emergency in the dental surgery include those taking oral medications in addition to inhaled medication and those who regularly use a nebulizer at home. Those who have required oral steroids for their asthma within the last year and those admitted to hospital with asthma within the last year represent high risk patients. 11 Minimising the risk Patients with Asthma should be identified by the medical history questionnaire and frequency and type of medication will give the General Dental Practitioner an indication to the degree of risk that the patient is under. The appointment times should not interfere with the patients medication times and the patient should have access to their inhaler should the need for it arise. Patients should be kept as calm as possible, waiting times kept to a minimum and appropriate anaesthetic administered to minimise stress. Diabetes A diabetic patient may suffer from two forms of diabetic crisis, which if left untreated, can lead to a diabetic coma: Hyperglycaemia Hypoglycaemia Diabetes is a condition in which the body fails to regulate the concentration of sugar in the blood. The Resuscitation Guidelines Council states Insulin treated diabetics are those most likely to become hypoglycaemic whilst at the dental surgery. Diet or tablet controlled diabetics are a much lower risk. Diabetics with poor control or poor awareness of their hypoglycaemic episodes have a greater chance of developing problems. 12 Page 5 of 8

6 Minimising the Risk The Diabetic Patient should be identified from the Medical History. The appointments for the diabetic patient should be scheduled so that they do not interfere with their normal meal times and medication and care should be taken not to keep patients waiting too long for their appointments. Stress levels should be kept to a minimum. Allergies The most severe allergic reaction is Anaphylaxis which is classified by the Resuscitation Guidelines Council as a severe, life threatening, generalised or systemic hypersensitivity reaction. There is the potential for this to happen in the dental surgery if the patient has a severe reaction to a drug that may have been administered by the Dental Practitioner. This may be penicillin or local anaesthetic. It could also result if the patient comes into contact with certain substances such as the latex in surgical gloves. It is not common in its severest form. 13 Minimising Risk It is extremely important that any allergies are picked up from the Medical History Questionnaire and that great care is taken not to expose the patient to any of the substances or drugs that the patient may be allergic to. If the latex in the gloves is the problem latex free gloves can be used. It is also important to be aware of the symptoms of Anaphylaxis as allergic reactions can occur without any previous history. Epilepsy Epileptics usually have a history of the disease and so again this patient group should be identified by the medical history and the patient should be further questioned as to whether their Epilepsy is controlled. Additionally, the patient may be aware that an attack is about to take place and may be able to warn the Dental Practitioner. The Resuscitation Council Guidelines state Factors that should alert the Dental Practitioner to a higher risk are poor seizure control and a recent change in medication. Enquiring about the timing of and precipitating factors for the last three seizures is a sensible risk precaution. 14 Minimising the Risk Epileptic Seizures can be triggered by stress and anxiety so attention again should be given to make sure waiting times are kept to a minimum. The nervous patient should be reassured and appropriate anaesthetic given to make the procedure is pain-free. Patients should take their anti convulsion medication as normal prior to a dental appointment. Clinical considerations for the dental nurse As a dental nurse you should be prepared to assist the dentist should a medical emergency arise. Familiarise yourself with patients that may be considered to be at a higher risk of a medical emergency during treatment, ensure that a system is in place to check the drug kit and expiry dates and ensure that you would know where to locate the drug kit should an emergency arise. You have an important role in reducing anxiety in patients as you prepare them for treatment. Try to keep waiting times to a minimum and if Page 6 of 8

7 there is a delay in seeing the patient let them know. If the patient is diabetic ensure that any delay will not interfere with the patient s meal times and medication. Portfolio Tip When completing your Personal Development Portfolio consider what you have learnt from this article. Do you realise the importance of having an up-to-date medical history? Are you able to identify those patients that may be at greater risk of a medical emergency and would you know which drugs and equipment you would need to locate from the emergency drug kit should the need arise? Non- Verifiable CPD Tip Consider further reading you may wish to do as a result of reading this article. You should ensure that the information contained in this article continues to be up-to-date. You can visit the Resuscitation Council regularly to update your knowledge. You can follow the links to the General Dental Council website which contains the standards that you need to follow as a dental care professional and you can also read more about some of the medical conditions contained within this article by following the links from the non-verifiable CPD section. Don t forget to enter everything you read into your non-verifiable CPD log. Coming soon.how to manage a medical emergency 2009 Nicky Gough and Sue Bagnall All rights reserved. 1 Atherton, G.J., McCaul, J.A., Williams, S.A. (1999) Medical Emergencies in general dental practice in Great Britain: their prevalence over a 10-year period. British Dental Journal, 186, pp General Dental Council Standards Guidance. (2006) Principles of Team Working. London, The General Dental Council. 3 General Dental Council Standards Guidance. (2008) Continuing Professional Development for Dental Care Professionals. London, The General Dental Council Page 7 of 8

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